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STATE OF CALIFORNIA` WATER RESOURCES CONTROL BOARD �s <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE "sIr <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT LVS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT Ll6 TEMPORARY SITE CLOSURE J ICv' <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME p CARE OF ADDRESS INFORMATION <br /> �a IJKI CT NS <br /> 'Mm (z .0c r$dN <br /> ADDRESS NEAREST CROSS STREET ✓9m to iAute 0 PARTNERI 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY <br /> a2,6S rj 0 INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> ptv CA 52015 20 —6 <br /> TYPE OF BUSINESS @ DISTRIBUTORE] 4 PROCESSOR I/EGA Box it INDIAN EPA ID 0 N of TAN <br /> ❑ 1 GAS STATION [:]3 FARM OTHER ESERTRUSTYLANDS ATION o ❑ 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 N WITH AREA CODE <br /> V lNPS z - 6 -d? Loop J0GIN 20 - 6 "6'T�i L <br /> NIGHTS. NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE b WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME may` CARE OF ADDRESS INFORMATION <br /> YS <br /> MAILING or STREET ADDRESS ✓Box m iritlicale 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 /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to io0icate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE Jr.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. ❑ 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# rrJURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> ol o ( g D101 Ole.' W <br /> V;t <br /> FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 26PERMIT APPROVAL DATE PERMIT E%PIRATION DATE <br /> EF <br /> S TRACTN SUPERVIS^R-DI TCODE BUSINES,PSNFILED NO ❑ DATE 187 C* <br /> RMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p /Q BY/: (/\ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST Or N MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \ <br /> FORM A(3-2-88) J/ <br /> \F <br /> DATA PROCESSING COPY *4W/' <br />