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STATE OF CALIFORNIF WATER RESOURCES CONTROLBOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM =" a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `^t�roxN`r <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 fEBMAUEUT.LY CLOSED SITE W <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Z <br /> tvt <br /> ck os 1 'V' <br /> fc(, OSSEUS <br /> ADDRESS A� NEAREST CRCISIS33 <br /> ✓Box to vdkak ❑ PAITNEASHIP ❑ STATEAGENCY <br /> OD E. 14 2 U ,qu�I> ❑ COAPDAATIGN ❑ LGCAL AGENCY ❑ FEDERALAGDO <br /> NCf <br /> CITY NAME $TATs SITE PHONE p,WITH AREA CODE <br /> MeuN4czz, CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p IF of <br /> ❑ 1 GASSTATION ❑ 3 FARM �OTNEfl RESERVATION <br /> ❑ U�k� AT7HASSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(IAST,FIRST) PHO E p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ,� 2 <br /> masselfis - GlN k <br /> NIGHTS: NAME(LAST,FIRST) PHOKE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> w Ic-, I UN <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE VpA''DDRESSINFORMATI N , <br /> rck N C QSSeI(tS <br /> MAILING or STREETADDRE 5 ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �zm0 - j 1� ( ❑ CORPORATION ❑ LOCALAGENCYCl FEDERAL-AGENCY <br /> VVVV Vlly t` �{DIVIDUAL ❑ COUNTY-AGENCY <br /> CUVN E STATE ZIPCODE ONE WITH AREA CODE <br /> sole9'53S:5 <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ii.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. ❑ 1 IV 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 /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION k AGENCY M FACILITY ID# #of TANKS at SITE <br /> 5H = = lolol "pzlil0imOb <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> CK m f0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> NA <br /> LL <br /> CENSUS TRAACCT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OAT(�FILLED�j j <br /> �3 )O o pZ YES NO ,( L 1 DO c ('r' <br /> PERMIT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> DATA PROCESSING COPY <br />