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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD Oe <br /> .T <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE IQ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1KCHANGE OF INFORMATION ❑ 7 P RM€ ANEN LY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S3 z <br /> IO <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NA E CARE DDRESS INFORMATION <br /> ADDRESS NEARES S TREETNmQicale CI ❑ <br /> ✓ STAiE-AGENCY <br /> 9 G P=014 ❑ LOMAGENCY ❑ F,'DERIL.AGENC7 000 <br /> ❑ INDNDWL ❑ CWNIYAGENLY <br /> CITY NAME STATE ZIP O E_ ITE PH E N,WITHV CQDE, <br /> rAAdds CAI <br /> TYPE OF BUSINDISTRIBUTOR ❑4PROCESSOR ✓Box if INDIAN EPA ID # 3 #�o��,[T�SMa�9//`i/ <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION o ❑ N/ AT THIS SITE V d <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NA E(IAST,FIRST) PHONE#WITH AREA COCE <br /> _ 27 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS ME(UST.FIRST) E#WITH AREA CODE <br /> sA <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE Of PRESS INFORMATION <br /> MA/JL/�dCJ�`v]QrJvST- ADDE/SSpn ] C ✓ x'0 in"cate El PARTNERSHIP ❑ STATE-AGENCY <br /> T rN Vex // (/ �DRIVIDUALIDN LOCAL-AGENCY 0❑ COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY N STATE ZIP CODE PHONE p. IT AREA CODE <br /> Of r3-1L <br /> III. TANK OW ER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMEV, CARE F OGRESS INFORMATION <br /> MAILI or�.S)TREE,7(pDDRES xto indicate C PARTNERSHIP ❑ STATE-AGENCY <br /> �V if YDV INDVDUALION 11 LOCAL-AGENCY 13❑ COUNTY AGENCY FEDERAL-AGENCY <br /> CITY AME STTA,TE 2IaQ0 DEPHONE✓#I 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. ❑ II. 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 M AGENCY# FACILITY ID If If of TANKS at SITE <br /> ® oo I 4q IL 1g, (51c) I o0 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> o� rc.oa <br /> MD 9,1L so <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> rCHEC <br /> ATION CODE CENSUS TRACT# SUPERVIS R-DISTRICT CODE BUSINESS P D FILED <br /> NO D <br /> 3 z3-fYES <br /> K# PERMIT AMOUNT SURCHAR.EAMIJUNT] FEE CODE RECEIPT# BY: <br /> ` ITINS 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 /> DATA PROCESSING COPY <br />