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M^�.r`P'$�[St''i!i!m*,p.�,�.r""- ...-.-�c,� `�r-= --..-.+.. -,•+�.,--T�w -ter^ --'�"�`' <br /> 7W <br /> STATE OF CALIFORNI WATER RESOURCES CONTROL BOARD <br /> f .uxeK�•.NF <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM &0 <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE ""FORN`D <br /> MARK ONLY ❑ f NEW 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 z <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Po to Se `ce W, E, C i ffi Y, M r. <br /> ADDRESS r l e' 1 C NEAREST ROSS STREET ✓ oz to indicate ❑P ARTNERSHIP ❑ STATE-AGENCY N <br /> I J� n � // �C�A i i I CORPORATION LWMCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I (J C.l �V '50K (0(� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> 4L K 4b- <br /> CITY NAME STATE ZIP C S E PHONE#,WITH AREA CODE <br /> S o c 7 o CA p sra 09)�"�pc1- k3/I <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RE <br /> ❑ RE <br /> ❑ TRUSTVATION LANDS or ❑ /✓ 0 r" e_ AT THIS SITE <br /> 1 GAS STATION 3 FARM 5 OTHER <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 /> M - E. C l+Yy\ a,0q) `f&q-g,31) ill C_ <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> i r tj i er Ser t)ic-e- M ' E, CAm Mqt- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Q ❑ STATE-AGENCY <br /> VJ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERA -AGENCY <br /> Dorado , ❑ INDIVIDUAL ❑ COUNTY-AGENCY Iza <br /> CITY NAME STATE ZIP ODE PHONE#,WITH AREA CODE <br /> C� a0� Cao) 'Le -8311 <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1 - <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 /> FPERMITNUMBER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> FT161011111513101 / <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ 3PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />