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STATE OF CALIFORNIA`S WATER RESOURCES CONTROL BOARD <br />FORM IA': UNDERGROUND STORAGE TANK PROGRAM <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FORM FOR EACKFACILITY/SITE <br />MARK ONLY ❑ 1 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< -z <br />1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />FACILITY/SITE NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />ADDRESS <br />3 <br />Ne <br />NEAREST CROSS STREET <br />✓Ba bidour ElPARMERiHIP ❑ STAiE AGENIX <br />❑COR PAnON 11 LCCA AGBK 0 PEDER AG N <br />❑ Irvgvleuu El ccuRry AGENCY <br />CITY NAME <br />{. � <br />gp� <br />STATE <br />CA <br />ZIP CODE SITE PHONE N, WITH AREA CODE <br />95236 <br />TYPE OF BUSINESS: ❑ 2 STRIBOTOR <br />❑I GAS STATION FARM <br />F—]4 PROCESSOR <br />❑ 5 OTHER <br />✓ Box if INDIAN <br />RESERVATION or F-1 <br />TRUST LANDS <br />EPA ID N <br />CITY NAME <br />S of TANK'1 <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />NIGHTS. NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME <br />l3eckht <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET XIDDRESS <br />0 CORPORATION 0 LOCAL -AGENCY 0 FEDERAL -AGENCY <br />APPROVED BY NAME PHONE N WITH AREA CODE <br />✓Box to intlicate 0 PARTNERSHIP 0 STATE -AGENCY <br />CITY NAME <br />{. � <br />gp� <br />ZIP CODE PHONE N, WITH AREA CODE <br />❑ CORPORATION 0 LOCAL -AGENCY ❑ FEDERALAGENCYN <br />A10 <br />CENSUS TRACT k <br />Z <br />0 INDIVIDUAL 0 COUNTY -AGENCY <br />CITY NAME <br />DATE FILED <br />b /� <br />CHECK R <br />STATE <br />I ZIP CODE PHONE N. WITH AREA CODE <br />FEE CODE <br />RECEIPT K <br />5',�-6 <br />III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />I/ B.. t.,nd,cate 0 PARTNERSHIP 0 STATE -AGENCY <br />CURRENT LOCA�ENCY FACILITY IOyr� <br />(�j!(/rJ KL �f/� <br />0 CORPORATION 0 LOCAL -AGENCY 0 FEDERAL -AGENCY <br />APPROVED BY NAME PHONE N WITH AREA CODE <br />Cl INDIVIDUAL 0 COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE N, 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. ❑ it. Pf Ill. ❑ <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 R <br />JURISDICTION K <br />AGENCY M <br />FACILITY ID If S of TANKS at SITE <br />CURRENT LOCA�ENCY FACILITY IOyr� <br />(�j!(/rJ KL �f/� <br />APPROVED BY NAME PHONE N WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LO TON CODE <br />C71Z3. <br />CENSUS TRACT k <br />Z <br />SUPERVISOR -DISTRICT CODE <br />BUSINESS PLAN FILED <br />YES [:]NO <br />DATE FILED <br />b /� <br />CHECK R <br />PERMIT AMOUNT <br />SURCHAR EOUNT <br />FEE CODE <br />RECEIPT K <br />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 />FORM A (3-2-88) <br />DATA PROCESSING COPY <br />