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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> S '•lYl.e� .�f <br /> FORM `A': '` ` <br /> UNDERGROUND STORAGE TANK PROGRAM _ ,�o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r '.° ,. �� ' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANCE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I�` <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ fi TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> Cn <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS IeJIGa� ct NEAREST CROSS STREET ✓9mU,gcale ❑ P�1iER9* ❑ STATE-WAVY <br /> ISO t J (apqannej�7�' ❑ COI TIN [�-LWW AGENLY ❑ FEMIkI.-AGEN9 <br /> Op ❑ WMINA D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> I �:] 11-9 <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 P OCESSOI) ✓Box if INDIAN EPA ID N <br /> ❑ of TANK's <br /> I GAS STATION E]3 FARM 5 OTHER 7RUSTVLANDS ATION ur ❑ 4/" ),Le-' AIS SITE L/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS' NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> AGC e 11&.,4 r av - <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S Ck Y� <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STAEJA ADDRESS ,may ✓Box to indicate ❑ ARTNERSHIP Cl STATE-AGENCY <br /> ! L ! C Cl INDIVIDUAL D COUNTY-AGENCY ClNCY FEDEHAL•AGENGY <br /> CITY NAME STATE ZIP CODE PHONE it,WITH AREA CODE <br /> S C,/,q I <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,S o,, + cc S R b D-v-e— <br /> MAILING or STREET ADDRESS ✓Box io indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY Cl FEDERAL--AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)SOX INDICATI�fG`W,C!1 E$OHOULO BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. III. ❑ <br /> THIS FORM HAS BEEN CONPPLEER PENALTY OF PERJURY,AND TO'THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> i <br /> APPLICANT'S NAME jPHIN SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> ❑ 1010lz 10 D 10Q I D <br /> CURRENTLOAL AGENCY FACILITY 10 S APPROVED BY NAME PHONE I WITH AREA CODE <br /> Y <br /> PERMIT NUMBER PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OAT FILED <br /> 01 a YES ❑ NO ❑ A, <br /> CHECK# PERMIt AMOUNT SURCHARGE AMOUNTFEE CODE 1�7 <br /> N . <br /> Li <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORMA(3.2.88) <br /> DATA PROCESSING COPY ti-1 <br />