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"'o' '+.i'nv�' 9'4 ' ^%aw�.,,s-w=r^,v,+,a.+•nwo-Rv gq "'rz«nwt .-,., w ---.7++- <br /> I <br /> STATE OF CALIFORO WATER RESOURCES CONTBOARD <br /> I �,••"F...k,. F <br /> FORM `A': <br /> t UNDERGROUND STORAGE TANK PROGRAM dm <br /> I SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "kipORNlP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I <br />' Id <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Plo61 I Service4'= 2- 1CR2e 64 A6 rV <br /> ADDRESS / NEAREST CROS STREET ✓EI le ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 7 // 1 �� ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY v+ <br /> �,J A INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA5-3_Z - T7 45 <br /> TYPE OF SINESS: ❑ 2 DISTR BUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> STATION 3 FARM 5 OTHER RESERVATION or `V #of TANK's <br /> 1 GAS S <br /> ❑ ❑ TRUST LANDS ❑ IO� 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 /> NIGHTS: NAME(LAST,FIRST) PHClqE#WITH AREA CODE NIGHTS: NAME(LAST, IRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> b . NJavprra. jr <br /> MAILING or STREET ADDRESS ✓Box toadicate PARTNERSHIP ElSTATE-AGENCY <br /> I ❑ r," ORATION ❑ LOCAL-AGENCY EIFEDERAL-AGENCY <br /> ^}" .,,OIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER IN ORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME O iL <br /> CARE OF ADDRESS INFORMATION <br /> mobil <br /> MAILING or STREET ADDRESS �✓Bo o indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> PetP�� IWC`CS'RPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> w&— ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> CCS PHONE#,WITH AREA CODE <br /> OO _ <br /> IV. LEGAL NOTIFICATI AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLIN : I. il. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CO3RECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> F <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE/ � 9 � 0 L4 <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODEPERMIT APPROVVALDATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT� SUPE VIS I�T CODE BUSINESS PLANFILED DATE FILED ��YES NOPERMIT AMOUNT SURCHARGE AMOUN FEE CODE RECEIPT# 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 />