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STATE OF CALIFORNIA WAitnRESOcis G NTROL BOARD <br /> FORM A: UNDERGROUND STOR TANK PROGRAM = " o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION s <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE SO <br /> ORM' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE a <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CD; <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> *(&Kl N 67T'a1 A0.1YOW45 <br /> ADDRESS NEAREST CROSS STREET ✓BOfNindcale ❑ PNRNmr 0 SfATEAGENC1 <br /> 63S 5. A140)* IrGAPOIATIoii D LDaLAGEND D FEOERALAtIm <br /> ❑ INDIVIDUAL 0 ODUMAGENCV <br /> CIN NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> 5To�oN CA �ir,2a I <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID A <br /> M <br /> RESERVATION or ❑ of TANK1 <br /> ❑ 1 GAS STATION ❑3FMM ❑ 50THER TRUST LANDS ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(EAST,FIRST) PHONE a WITH AREA CODE <br /> /t4L(r©AIt- 4 ,4L-1,W (ZaY) -4'�2-cF4ZZ Q4e , —jaG q,(2- 4y2Z <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> N� <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME H CARE OF ADDRESS INFORMATION <br /> (SKIUAL <br /> MAILINGor STREET ADDRESS ✓Box to indicate EFPARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> -3,5 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> 57Z'G/ d� Ck I ?5Zo I <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STP ETADDR SS x to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> D• ► 29 , <br /> oG D CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME /, STATE ZIP R7Cti l ZPHONE <br /> �WITH <br /> grAREA ZCgg2-Z, <br /> O <br /> l\ <br /> i R <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. 11. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N W ITH AREA CODE <br /> IkIG <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR- (STRICT CODE BUSINESS PLAN FILED DATE FILE ( ) <br /> 2 YES NO 8 194b V" <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY. \ �J <br /> THI RM MUST BE ACCOMPANIED BY AT LEAST(1)OR BARE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. (� <br /> FORW.A(3-288) \ \' <br /> 1, \•,\ >ill"I DATA PROCESSING COPY <br />