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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> r <br /> FORM A : <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �•oa"`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION [Ori`PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE 63 <br /> '4T <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 10 <br /> FACT /SITEN`AfME ^ � CARE OF ADDRE INFORMATION <br /> 195 <br /> ADDRESS f 1 //L�'/ C NEA REST/_✓0L/S�S�STFEET ✓B 11PARTN901P 1:1 STATE AGENCY N <br /> IDI�MII&DUA11 WUNry-AGENCY <br /> ❑ FEDER4-AGENCY <br /> CITY NAME � STATE 21P qr-2 0 SITEPH E N,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID# C�� /T' <br /> RESERVATION or ❑ #of TANK's <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 N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> /fwie- /V6"v-v_ <br /> NIGHTS: NAME(UST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE If WITH AREA CODE <br /> NoA/ci., Alf)AJ <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> - <br /> MAILINGorSTREETADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME / /T./' ' /..J LLC �/T� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ 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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If If of TANKS at SITE <br /> AM 10 0 l Oho 4 <br /> CURIA <br /> E LOCAL AGENCY FACILITY ID R APPROVED BY NAME PHONE N WITH AREA CODE <br /> AGF( ;1- "?, / <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> CNECKN PERMIT 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 IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> �-- �� DATA PROCESSING COPY a N-asmill <br />