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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u <br /> SITE 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 ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> r5_3_1 CA <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 00 <br /> FACILITY/SITE NAME CARE OIF ADDRESS INFORMATION <br /> VOX)btdf� RlAm( CaA F e oN <br /> ADDRESS NEAREST CROSS STREET ✓Bo WooXp 0 PA6TNERSHP 0 STATEAGENCY <br /> Amjus N O Ica NIDUA! O eaiNTv AG OCKAGRO [I RLfPAI AGENLY <br /> CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> e— CA 5.58 2 -369 - YS <br /> TYPE Of BUSINESS: DISTRIBUTOfl ❑4 PROCESSOR ✓Box X INDIAN EPA ID a <br /> ❑ I GAS STATION ❑ 3 FARM Q 5 OTHER RESERVATION of ❑ - X of TANK's �( <br /> TRUST CS <br /> CfKN ATTHISSITE !YY/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> ep m sf -/11/5 <br /> �i1� <br /> NIGHT$: NAM (LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> I7 fs AO?-3C? -1911S <br /> O <br /> II. PROPERTYWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMEr /_ CARE OF ADDRESS INFORMATION <br /> wandbTf t4eC-WA j <br /> MAILING or STREETA DRESS ✓BOx to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> QS T ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> y 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE 777 PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> .1 CARE OF ADDRESS INFORMATION <br /> � <br /> INOir - asl <br /> MAILING or STREET ADDRESS %/Box to Indicate ❑ P RTNERSHIP 0 STATE-AGENCY <br /> e60 CORPORATION CAL-AGENCY 0 FEDERAL-AGENCY <br /> ,�• X. I Cl INDIVIDUAL COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> wflddkr66 (:W 1 '7,4725_8x' <br /> s— <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BE$T OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION X AGENCY X FACILITY ID X N of TANKS at SITE <br /> O D 2 1 3 I 8 I I I 10 100 10 <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE <br /> O� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ^O /% res ❑ No El �2/97 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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(3-2-813) <br /> +�C DATA PROCESSING COPY ~ <br />