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STATE OF CALIFORN ? WATER RESOURCES CONTR� <br /> OARD s".'••�� "�F <br /> FORM 'A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> / FACILITY/SITE, INFORMATION and/or ERMIT APPLICATI ' Z <br /> C/ _ o 0 0 <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE rq� °+ ,P <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION UUUU <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE r <br /> 2 INTERIM PERMIT q AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE 4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> X4/rN o (,— FA GY2s4inK <br /> ADDRESS <br /> NEAREST CROSS STREET ✓PmbidicMe ❑ PARTNERSHIP ❑ STptE-ACbVp <br /> S. A /R U„'� ✓” ❑ 00 RATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CO� <br /> CA <br /> s13INOIVIDAL O COUNIYAGENCY <br /> Z06 D SITE PHONE#,WITH AREA CPDE <br /> TYPE OF BUSINESS: [] p DISTRIBUTOR OCESSOR ✓Box if INDIAN EPA ID # <br /> 1 GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ - X of TANK'# <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAS'FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> (/ ;A B^ w PHONE#WITH AREA CODE <br /> L ,x'' -0 lG p -a7, <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME( T,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME _�� ^�Y,� � CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS r/,[ I'Ar ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S r / - ❑ CORPORATION 1:1 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> A �•J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> --/)Z�� <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAKING or STREET ADDRESS ✓Bax 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 1:1 it. ❑ 111. <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# JURISDICTION If AGENCY# FACILITY ID If #of TANKS BI SITE <br /> ® = = 1aD1 Zlgl &71f 10U 102 <br /> CURRENT LOCAL AGENCY FA LITY ID X APPROVED BY NAME PHONE X WITH AREA CODE <br /> ��-en/8z6 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 1177 f0 Ll <br /> 24 YES NO <br /> CHECK# PERMIT AMOUNT SURCHARG AMOUNT FEE CODE RECEIPTM BY/ , <br /> W <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)_gA MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> y ORM A(3-2-88) <br /> �� DATA PROCESSING COPY *.\/ <br />