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STATE OFF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 N PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUR L3 1 Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FA LITY/SITE jGAKOF ADDRESS INFORMATION <br /> tilv 14 Av MnTP d leo 110 r s <br /> AREST CROSS STREET Bm e ❑ PAATNE ❑ STATE AGENCY N <br /> A ESS /, / - ' �^ / APOAATION LOCAL [IFEOEAAL AGENCY (,J� <br /> oWS ❑ womcuAl ❑ COUNTY AGBEN+CY N <br /> ITY NAME STATE CODE SI PHONE 0,WITH AREA CODE <br /> /Y( CA !( <br /> TYPE OF BUSINESS. ❑ 2DIST UTOR ❑ 4P5R ESERVATIODIAN <br /> N or EP ID a Mot TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHEH TRUST LANDS ❑ I� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D NAME(LAST.FIRST) PHONE N WITH AREA CODE D - NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> HTS'. NAME(LAST,FIREPre 1PHOIGfEa WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> AME OF ADDRESS INFORMATION <br /> 7 69nt E oy <br /> NO or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> NAME STATE ODE VNNE K,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> ry y/� F ADDRESS INFORMATIONS ep <br /> G or STREET ADDRESS ✓Box tc Intl¢ate Ll PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION Q LOCAL-AGENCY 11FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> NAME ` S TE ODE P A,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: I. ❑ 11. ❑ Ill. ❑ <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 /> LO AL AGENCY USE ONLY 7`! <br /> tECK# <br /> JURISDICTION M AGENCYM FACILITY IDM 7� of TANKS at SITE <br /> la 3v o0 0 �GENCYILIIT iD APPROVED B PHONE N WITH AREA CODE <br /> U T APPROVAL DATE P MIT E IRAT N DATE T TNUP�VI50 -DIST T CODE BUSINES YP S[❑FILED NG ❑ D EO��IT AMOUNT <br /> MU 01 <br /> AMOUNT FEE CODE fill 2 <br /> RECEIPTN 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(3-2-88) <br /> `PW DATA PROCESSING COPY %wo <br />