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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'��•�s"'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> W <br /> FACILI /SITE NAME CARE OF ADDRESS INFORMATION <br /> Er0a W `aw a;I1ero <br /> ADDRESS , NEAREST CROSS STREET 'We!d,uws ElPARfNFASHIP 11Sfg1FAGENLY <br /> 185 cr IP ❑3IINNDVIDOIAL" 0 �NTY�CY ❑ u-ACBc <br /> CITY NAME STATE ZIP CODE , SITE PHONE#,WITH AREA CODE <br /> -S �o t, •�-t CA 5 (2 047) S &;- u,69 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑d PROCESSOR -/Box B INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> r o ao 5- <br /> NIGHTS: NAME(LA .FI T) ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S Cil <br /> II. PROPERTY OWNER INFORMATION &ADDRESS —(MUST BE COMPLETED) <br /> Ni q CoARE OF ADDRESS INFORMATION <br /> • b �N cZN <br /> MAILINGor STREET ADDRESS ✓yS xta indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 13'CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY _ <br /> CITY NAME S-I/ C�1<4&%V� SZ/9 ZIP CODE PHONE 01,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> sa4-0-t as ory6ple-Inowner <br /> MAILING or STREET ADDRESS ✓Box to iWicate ❑ PARTNERSHIP 11STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If.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. If. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS rguE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# FACILITY ID# It of TANKS at SITE <br /> = = = 10101 /js 6o0 ;- <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE If WITH AREA CODE <br /> GDT6L 9• <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT#�1 SUPERVISOR-D1STRICT CODE BUSINESS PLAN FILED DATE FILED <br /> • Iry <br /> a YES NO / <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY <br /> THIS FORM MUST BE ACCOMPANIED BYAT LEAST(1)OR Mou TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOPM A 1a-2-ear / <br /> ' DATA PROCESSING COPY <br /> �� <br />