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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM 1 �e <br /> SITEr FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT [P"5CHANGE OF INFORMATION ❑ 7 PERMANENTLY D SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑fi TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) •Ww.+ <br /> FACIUTY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS /�/ NEAREST SS STREET j ✓BMWY�- 13PAITINO P 11 STATE �B <br /> Y ❑ WIPOMTKKI 0 LOCILAGBII,Y ❑ FEBBDLAGEha <br /> ❑ IMMIX 0 CORY-AGENCY <br /> CITY NAME STATE <br /> CA PIPCODE SITOWI�A�7EA COD <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCf5S011 ✓Box if INDIAN EPA ID N RESATION N p(TpNK'A <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUSTT LANDS OT ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> e p&✓e - -"6 cs el& zo — 9s ads <br /> NIGHTS'. NAME(LAST,FIR ) PHO E# ITH AREA CODE NIGHTS: NAME( q8T,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME �—LOr G� �- �g�lj(IU CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Sox to iMicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> A/N 0 INDIVIDUAL 0 COUNTY-AG CV <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION <br /> 4/l.' <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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 44 BILLING: E II. ❑ m.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF Y KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCYAr FACILITY ID# #of TANKS at SITE <br /> lJ 10 ° 161 <br /> d ° <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION ODE CENSUS <br /> �TRACT N SUPERVISOR-DISTIi1CT CODE BUSINESS PIAN FILED DATE <br /> /FILED <br /> !/ (l Z-Za - YES NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:�� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LF'oT(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S). UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1' <br /> FO M A(3-2-88) ✓ 1 (�� <br /> DATA PROCESSING COPY — / l <br />