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STATE OF CALIFORNIP WATER RESOURCES CONTRAOARD <br /> °'E'`ueifi rN\ <br /> V e� TFF A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> !ta <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> ID <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ac ' G r' eeoVVI <br /> MIial Fuelin ro <br /> ADDRESS NE le ❑ PARTNERSHIP 11 STATE AGENCY CAkm RTO <br /> IRI ^Q C( - �( G A v e �%nN <br /> ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY •�, <br /> ❑ INDMDUAL ❑ WUNTY-AGRO {Fili1 <br /> CITY NAME ] STATE z1ftae Slip PHONE it,WITH AREA CODE <br /> CA 'a D o9 ikPlv-�Pa l <br /> �TYPE F BUSINESS: ❑2 DISTRIBUTOR F__] 4 PROCESSOR ✓Box if INDIAN EPA ID p X of TANK'# <br /> GASSTATION ❑3 FARM ❑ 5 OTHER RESERVATION or �n <br /> TRUST LANDS 11 NO /I/ �+' 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 /> b4u'i [) aae �- Pa <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> sa4r-eao2 7-aa <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> CQ lI I ct- Ftx <br /> MAILING or STREET ADDRESS ✓Byt to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �1 �) INCORPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY <br /> '! V �- ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAMECODEPHNE 9,WH AREA CE <br /> S ) n STATE4 ZIP :?5AO CO.-OgIT't&& D���l <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME AA /� CARE OF ADDRESS INFORMATION <br /> C l IX e (form mer Li u.Q ru el, n <br /> MAI G or STREET RESS ✓gox to indicate 11 PARTNERSHIP 11STATE-AGENCY <br /> �] ®'CORPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCYI ^ O ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME -� STC ZIP CODE PHONE 12 12.5 WITH AREA S 9 a/ <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS 'T/ <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.9-1 <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# AGENCY# FACILITY ID# #of TANKS S7 SITE <br /> al = = 10d 1 I ja 0603 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �;� G, -a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DI CT CODE BUSINESS PLAN FILED DATE FILED vv <br /> 3 1 YES NO /$ (30 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT f S . <br /> THIS FORM MUST BE ACCOMPANIED BYATLEAST(1)OR MORE TANKPERMIT FORM `B'APPLICATION(S), UNLESSTHIS ISA CHANGE OFSITE INFORMATION ONLY. <br /> t') I <br /> FORMA(3-2-88) 10 � <br /> DATA PROCESSING COPY <br />