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STATE OF CALIFORN19 WATER RESOURCES CONTR•BOARD <br /> SE l�f <br /> A <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C, COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•�e_"-`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �` -4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) Om <br /> 4b- <br /> FACILITY/.SITE NAME CARE OF ADDRESS INFORMATION <br /> tf 44' NG <br /> ADDRE NEAREST CROSS STREET ✓Bu Io4Miorw Cl PARTNERSHIP ❑ STATE AGENCY <br /> 33 33 �. CI CORPORATION ClLOCALAGENCY ❑ EEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> yX klnN CA aos- 2dT -Ss,06 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or Al of TANK's <br /> ❑ 1 GASSTATION ❑ 3 FARM [jV5 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(I-AST,FIRST) PHONE#WITH AREA CODE <br /> KcAe-ki"NClNAJ -!F956 <br /> NIGHTS'. NAME(LA T,FIRST) IPHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME + CARE OF ADDRESS INFORMATION <br /> l £ Q�L� .l�L <br /> MAILING r STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> -aX 57 / ❑ CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 06 11INDIVIDUAL ❑ COUNTY-AGENCY <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 /> Pi <br /> MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. V 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> r7 <br /> CURRENT LOCAL AGENCY FACILITY ID K APPROVED BY NAME -- PHONE#WITH AREA CODE <br /> K- C /�'At <br /> PERMIT NUMBER PERMITAPPRO <br /> AL DA PERMIT EXPIRATION DATE <br /> 171 zg <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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.0 <br /> \ FORM A(3-2-BS) /) <br /> 0 DATA PROCESSING COPY to <br />