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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m l o <br /> C / COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT Cy,tANGE OF INFORMATION ❑LE9MjAUU4TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUREI oil <br /> W <br /> Ia <br /> 1. FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) ~ <br /> FACILITY/SITE NAME � CARE OF ADDRESS INFORMATION <br /> J �N E <br /> ADDRESS NEAREST CROSS STREET ✓ft ElNAIWWIP ❑ STATE-AGM <br /> ❑ ilO <br /> -1 1 14RTF l ❑ LOCAL AGENCY ❑ FEDIR&AGDO <br /> INDMDAL ❑ ODINIYAGENC/ <br /> CITY NAME STATE CZIP CODE SITE PHONE p,W17HEE <br /> A 6-3 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR D S 3SOR W✓•Booz H INDIAN EPA ID It n(//V' �_'D <br /> N Of TAANK's <br /> ❑ 1 GAS STATION [—] 3 FARM 6 OTHER <br /> RESERVATION <br /> LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: AME( FIRST) NE N WITH DAYSNAME(LAST,FIRST) <br /> ST. PH ^ SPHO 74-7;06 <br /> NIGHTSNAME(LAST,,F ST) PHONNE#WITH AREA CODE NIGHTS: NAME(LAST,FI T) PHONE#WITH AREA CODE <br /> 4 kV -9 F- 00 1( <br /> It cc <br /> 11. PROPERTY OVAER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME /' � � CARE Of ADDRESS INFORMATION <br /> MAILING or STREET A SS /1J1.•,�T ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O , BQt, RPORATION 11LOCAL-AGENCYEl FEDERAL-AGENCY <br /> U INDIVIDUAL 11 COUNTY-AGENCY <br /> CIN NAME �o STAT ZIP CODE P ONE p,WITH AREA CODE <br /> S <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> gl�e�ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> IV INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Al,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. ❑ 11. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID 4 Is of TANKS at SITE <br /> [3ljl I o10 1116) Oct 6 <br /> CURRENT LOCAL AGENCY FACILITY ION APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O YES ❑ NO 3r—e—ff <br /> CNECK# PERMR AMO NT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST11)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-8B) � ^I <br /> DATA PROCESSING COPY <br />