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16— <br /> q.,:,Q m...:-. ,w,�na.WaR'W4r•.•--yy rt <br /> I <br /> p'STATE OF-CALIFORNI WATER RESOURCES CONTR OARD �F <br /> /S�PEV0.[l(0. Thp <br /> WP. Sa <br /> " FORM `A': >l <br />( UNDERGROUND STORAGE TANK PROGRAM <br /> I; SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '> T <br /> 1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °"0, RIO <br /> MARK ONLY "FW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE q <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION _ 110 <br /> ADDRESS NEAREST CROSS <br /> $ ✓B <br /> STREET ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1:1 LOCAL-AGENCY <br /> 00 229, " V 9 ❑ INDIVIDUALION 1:1 COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 9l9j*,T'j/` SITE PHONE#,WITH AREA CODE CID <br /> MA � CA vv AV5 -X7(_- <br /> TYPE TYPE OF BUSINESS: F_� 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑1 GAS STATION 3 FARM 5 OTHER RESERVATION or #of TANK's <br /> ❑ 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 If WITH AREA CODE <br /> NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA CODE NIGHA.: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME ) � CARE OF ADDRESS INFORMATION <br /> U .`A <br /> MAILING or STREET ADDRESS <br /> / j�✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �Ll INDRIVIDUALPORATION ❑ COUNTY AG NCY ElFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME // CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS — ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> .y`1, CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C/( C�f[� [T 41/f/ E? INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CA, SSG `-7`Y6 - <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOU(:q Rgul!I D FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> a APPLICANT'S NAME(PRINTED&SIGNATURE) / �1fsC��°���l�i. < DATE ►y/�) <br /> LOCAL AGENCY USE ONLY f <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [a�l I I I j �' [�:[ I I L I r I :�z I 6J �4 = I I ;�d <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBERv PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 1, F n' <br /> LOCATION CODE CENSUS TRAC SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED tI l:DATE FI D <br /> U YES NO,. ti <br /> CHECK# PER *MOUNT SURCHARGE AMOUNT ___[FEE CODE RECEIPT# i, BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY.;. <br /> L <br />