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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 `` ' f <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME � � CARE OF ADDRESS INFORMATION <br /> NEAREST CROSS ST T larA¢ale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ADDRESS <br /> / CORPORATION Cl LOCAL-AGENCY ❑ IEDERAL-AGENCY <br /> �� {�+' �' �'Y " O ❑ INDIUIOUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP COOF SITE PHONE N,WITH AREA CODE <br /> TG`�( CA 93�ly C9)$ IBJ - o(d4-Lo <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCES50R ✓Box it INDIAN FPA IDN q of TANK's <br /> RRUST A IONNDS or ❑ i a T'� 1 tam �9� � 4 AT THIS SITE �J <br /> 1GASSTATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ur1V ! �" .i' i <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,.FIRST) PHONE Y WITH AREA CODE <br /> F!�1I05ON I P (Z09)<8-2,4,-0646' PINNf,51r F'WA-W- 945-_7&?& <br /> NIGHTS: NAME(t-AST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRSTIh r�PHONE0WITH AREA CODE <br /> U1,106N, FVO NE &15)5&t-9-;a UN06pWOZ(mCNC-� <br /> I V C!T I X32 <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> VNkON O1LGo. 0� LA1_1�'OIZNIr�., ��-.UNC <br /> MAILING or STREET ADDRESS ,,,���rrr-������ �v, */_�0 K"o, <br /> P indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> v175ND• /-4 IL.0r 1P RPORAL ❑ LOCAL-AGENCY ❑ 1=EDERAL AGENCY <br /> I VLJ wr w-1 _ IVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE IF CODE PHONE WITH AREA CODE <br /> WP•1 13T C � �67b <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> UNION OIL- 4D- of <br /> MAILING or STREET ADDHESSi ,7,�,/,��, to indicate Cl PAHTNERSHIP ❑ STATE-AGENCY <br /> `�� No. /fir IrJyQI`I�� � I�� .0 Ls CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> N11-71 1`�r{''� C//"a`-1�`''9" ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY cIT'Y,WI�`✓,VLl1.. STATE ZIP DE <br /> G�4✓`��a `4ONE a T ' E5� <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. ❑ II- 9 III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> AP ICANT' NAME(P INTED 8 SIGNATURE) } `Y DATE <br /> LOCAL AGENCY E ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS of SITE <br /> CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> CHECK K PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT40T(1)OR MORE TANK PERMIT FORM `B` APPLICATIOI NLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-1113I <br /> DATA PROCESSING COPY <br /> ( <br />