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- <br /> t'� * i <br /> STATE OF CALLFOFIA WATER RESOURCES CONTROL BOARD <br /> 5E^� rN <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r� ado a <br /> V COMPLETE THIS FORM FOR EACH FACILITY/SITE ,�}FO R` Nt <br /> MARK ONLY ❑ l NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF tNFORMAT10N ❑ 7 PERMANENTLY CLOSED SITE I+ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Of <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 00 <br /> 00 <br /> FACILITY/SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> -q` <br /> ADDRESS NEAREST CROSS STREET ✓Bw 10 WicOt C1 PARTNERSHIP ❑ STATE-AGENCY <br /> 1 } M�� ElCORRmT*N ❑ LOCAL�AGENCY ❑ FSEIpALAGENCY <br /> v ❑ iNDN1pIlAL ❑ COIAYIYAGENCY <br /> CITY NAME STATE DP CODE SITE PHONE 4,WITH AREA CODE <br /> CA <br /> TYPE OF USINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR "'Box H INDIAN EPA ID It <br /> RESERVATION or N of TANK'B <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 4 WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> L-ubcV-6 4,5� 4 - 2_411 lIZ1u <br /> NIGHTS: <br /> NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> tFAYY. __r1AA LLTl <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br />'I NAME CARE OF ADDRESS INFORMATION <br /> nUT-H i _ r A)A T E <br /> MAILING or STREET ADDRESS ✓Bp�to indicate ElPARTNERSHIP ( STATF-AGENCY <br /> 2) ` 9-fORPORATION ❑ LOCAL-AGENCY EDFEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> �1 Eruru Z Cr- G <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1201 r'rr9-1 l (•, 'O t.j c. <br /> MAILING or STREET ADDRESS ✓Box to indicate © PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <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 /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS Ill SITE <br /> El D ED <br /> CURRENT "� <br /> LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �-7\j q <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRAACCTT# SUPERVISOR-DISTRICT CODE BUSINES'P 5 NFILED NO ❑ DATE FILE/A- <br /> CKECK# <br /> E 3, D `/ X11 f' ✓PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# $Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> LOCAL AGENCY COPY <br />