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STATE OF CALI FO R N IX" WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM _ 'moo Z <br /> SITE FACIL FORMATION and/or PERMIT APPLICATION 10 <br /> T FORM FOR EACH FACILITY/SITE <br /> I MARK ONLY ❑ 1 NEW 3 REN AL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> J ONE ITEM ❑ 2 INTERIM PERMIT 4 AME ED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 <br /> F (� <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) O <br /> 1 CJl <br /> FACILITY ITE NAME CARE OF ADDRESS INFORMATIO <br /> T 1 San4t gp I-C­ 4+ch i 56� <br /> ADDRES NEAREST C OSS STREET ✓8ozginrii L ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 3 3 G ' S O S'�' ❑ CORPDRATION 1:1 LOCAL-AGENCY ClFEDERAL-AGENCY <br /> J l., I 1-� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> I CITY NAME ^ �C '^ STATE ZIP(jDtC;�G� SITE PHONE If,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCE7'TRUSTVATION <br /> ✓Box if INDIAN EPA IDN N of TANK NRESE �\J <br /> ❑ 1 GAS STATION ❑3 FARM E] 5 OTHERLANDS or ❑ ""' AT THIS SITE V`--' <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 /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME � c��� f� K 1� CARE OF AD SS INFOATIOM <br /> 1 \ ao <br /> MAILING or STREET ADDRESS ✓Box to indicate I `n❑�1 PARTNERSHIP ❑ STATE-AGENCY <br /> Q 1 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> P <br /> boy, I i ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME . n l STATFr, ZIP�ODE� PHONE NOWITH Aq CODE <br /> S✓� (�f• _ / 3nI <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C�, <br /> UPJ JIBE ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME �J STAT ZIP CODE PHONE N,WITH AREA CODE <br /> Q(bL4 v (2> 1-) -sq H <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION k AGENCY k FACILITY ID fF M of TANKS at SITE <br /> 3 K2d l10 10 1 :61 <br /> CURRENT LOCAL AGENCY FACILITY IDN 1 APPROVED BY NAME PHONE N WITH AREA CODE <br /> r) 0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE FI ED <br /> 0 1 _C_;� Z15_,13 olleD YES ❑ NO )l <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNI FSS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> I � FORM A(3-2-88) <br /> � DATA PROCESSING COPY <br /> 1� <br />