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STATE OF CAL(FORNIA- WATER RESOURCES CONTROL-60ARD � <br /> FORMAUNDERGROUND STORAGE TANK PROGRAM r ALo Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1.1. 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> `°"��� <br /> MARK ONLYt NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANE SED SITE <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /w .82111 <br /> 01 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FCILTWSIT AME �/ CARE OF)OGRESS INFORMATION <br /> D E��f (dJJ(f q N ES CROSS STREET ✓ bp3nle ° PA17MMIP ° STATE-AGM <br /> Y D/ �- L•�•A-crkt , -l. o INWDUaAk °° -AA EN ° FB>eWAGEpcY <br /> CITY NAL1E�� , STATE ZIP CODE SITE PHON N.WITH AREA CODE <br /> LL CA , 6 CZo 369-S"6z <br /> TYPE D USINESS: 2 DISTRIBUTOREj 4 PROCESSOR ✓Boz N INDIAN EPA ID# N of TANK'# <br /> RESE1 GAS STATION ❑ 3 FARM ❑ 5 OTHER 7RUSTYANDS or ❑ /rD AT THIS SITE D�? <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS NAME(LAST,FI ST P ONE p WITH AREA 00 E DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> �/ S,,(,u•Cn.� LSI(, t/Z3 -/948 A A <br /> NIGHT61 NAME ST,FIR PHONE If WITH AREA CODE NIGHTS: AME(LAST,FIRST) P O Ea WITH AREA CODE <br /> S S SA <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF AD ESS INFORMATION <br /> MAILING or STREET ADDRESS ��✓gox toin0icate 0 PARTNERSHIP 0 STATE-AGENCY <br /> /q' p CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> • ` D/.0 6&t, 4 ° INDIVIDUAL ° COUNTY-AGENCY <br /> CITY N&4,tt&.� STATE ZIP CODE PHONE ,WITH AREA CODE <br /> alit 17 pi <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bortoindicete 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE 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. ❑ II. 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 /> COUNTYYI# JURISDICTION N AGENCY# FACILITY-ID N N of TANKS at SITE <br /> 3 ` = U V l J -2_ l/ 0 1 0 <br /> CUflflENT LOCAL AGENCY FACILITY ID N AP ROVED BY E PHONE N WITH AREA CODE <br /> c0 IV- <br /> PERMIT NUMBER PE IT PPROVAy DATE PERMIT dxPiRATKIN DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED <br /> 3 YES ❑ NO v Z6 <br /> CHECKN PERMIT AMOUNT 11URCH(ARGEf AMOUNT FEECODE I RECEIPTN 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) `DATA PROCESSING COPY \ <br />