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STATE OF CALIFORN1rL WATER RESOURCES CONTRtfe BOARD ,'A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM u " <br /> SITE Z FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 12!kPERMANENTLYCLOSED SITE 1'A' <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 0 ' <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAM CARE OF ADDRESS <br /> FOR <br /> to <br /> ADDRESS NEAREST CROSS S ✓�Sv wnOrak 0 PARPIERw 0 STATE-AGENGY <br /> _1 N�`COAPOMTION 0 LOGL-AGE.AV ❑ RLERALAGENC! <br /> M�(/�'�� 0 INDIVIDUAL 0 CWNtt AGENLY <br /> CITY NAM STATE ZIP CODEITE PHONE If,WITH AREA CODE <br /> CA k2ar 3 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p <br /> RESERVATION or ` #o1 TANK'# <br /> ❑ I CAS STATION [-] 3 FARM 5 OTHER TRUST LANDS ❑ K / v I 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 /> Es 2'i 8 2-963UKO <br /> NIGHTS: NAME(LAST,FIRST PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Mom Va ZZ -Y'1`7-70 T <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> , Jok <br /> MAILING or STREET ADDRESS _ ✓Box to ineicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> e=KJ „n (/y.L CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 11.•...r� I/V FT�SI ^ 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAM STATE DECODE PHONE N,WITH AREA CODE <br /> lHuckory 23r, (� N <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMEAM6 AS CARE OF ADDRESS INFORMATION ' <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L PVT I. ❑ If.❑ j <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# It of TANKS at SITE <br /> 00z O 10 1c) <br /> CURRENT LOCAL AGENCY4 <br /> FACILITY IOM APPROVED BY NAME PHONE#WITH AREA CODE <br /> M� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> N A <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O 2 3 � d YES NO ((2�_/ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE flECE1PT# 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.C' <br /> ORM A S-2-88) <br /> s^ DATA PROCESSING COPY �� <br />