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^E <br /> STATE OF, OALIFORN WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM W "°" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® ; �' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "`'FOR <br /> "" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEMIlm <br /> ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) .+ <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Rt o AM prK M(Q I KAP-IC-FT <br /> ADDRESSNEAREST <br /> f� p p �J� �j� NEAREST CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Zq�" D m LTAm I� r�`ALT D;" � El❑ NDRPORATION O COUNTY AGE LOCAL-AGENCYElFEDERAL-AGENCY <br /> IVIDUL CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> STack,-'F°N CA 15720 209- 471 5552 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ,sT-A&NAfyo, Jow- j 2oq- 47g- SSSy AtuO eQ6jR 415-57(-2A0O <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Pitz-60 Pv_0puC'7-;' Co. <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �1e I, Q- INCORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 2000 PsI,DrlVlt✓D� IQS �V�GA� ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 5 PsQ KATE-0c-A a 3 415_ <br /> q7 1-.240 0 <br /> I11. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Pp0puCT5 Co. <br /> MAILING or STREET ADDRESS <br /> A/� ✓fox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 000 A�F�'GPA de-14h hU� L❑9-NDIIVIDUALION El COUNTY AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME <br /> &A Al 1✓0 STATEZIP CODE O,, PHONE#,WITH AREA CODE <br /> 415- 5-71-dao <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. ❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDERLP TY OF P RJ Y,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNA RE) DATE <br /> PAVI, f, WILTON I1-21-qo <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> m <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS A FORM MUST BE ACCOMPANIED BY AT LEASTTT R MORE TANK PERMIT FORM `B'APPLICATION(S), U THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-881 '- <br /> DATA PROCESSING COPY <br />