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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> yEP� <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,1 <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT Lj 3 RENEWAL PERMIT 10 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM p INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 15—1 <br /> Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 1 C <br /> FACILITY/SITE NAME , I CARE ADDRE551IgFORMATION <br /> MPAT 0 1 L(fJiO S , '`1.52 <br /> ADDRESS / NEAREST CROSS STREET Imlbi ❑ PARTNERSHIP ❑ STA TEAGENCV IV <br /> 13 342 51 6 Q ` CORPORATION ElLOCAL-ADEN 1-1FEDR L AGENCY <br /> INDIVIDUAL ❑ COUNttA ENCY (3)CIN NAME STATE ZIP CODE <br /> SITE PHONE p,WITH AREA CODE �700 <br /> TYPEOFBUSINESS CA �^ T/ �V�2 <br /> L 2 DISTRIBUTOR 0 4 P CESSOR ✓Box if INDIAN EPA ID # <br /> 01 GAS STATION E:l 3 FARM 5 OTHER RESERVATION or ❑ #of TANK'# <br /> TRUST LANDSAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME ST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S I HOZ <br /> NIGHTS: NAVE(EAST FIR I PHONE AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S a / - Pv <br /> II. PROPERTY O NER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME A I/ CARE OF ADDRESS INFORMATION <br /> 7YTV Q, (� �/ <br /> MAILING or STREET ADDRESS r(/(V bindicate ❑ PARTNERSHIP ❑ STATEAGENCYO - CORPORATION 11 LOCAL-AGENCY 1:1 FEDERAL-AGENCY <br /> L/ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 5--tiSE v SS - <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> V CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTYAGENCYCITY NAME <br /> SSTAT ZIP C E PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS S <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. If. 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> C�L] o� cel o1 ZU0101 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> F�141/3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> © O VES E] NO <br /> CHECK# PERMIT AMOUNT BURCH RISE AMOUNT FEE CODE RECEIPT If BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> 41 <br /> DATA PROCESSING COPY <br />