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STATE OF CALIFORNIA , WATER RESOURCESCONTROL,)ARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �' Z <br /> -- -� % Ip <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 0 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F+ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMITL� <br /> ❑6 TEMPORARY SITE CLOSURE _J <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r l TI10 0I LL.L. c. q)'& �P.ILofr+4.c�1` <br /> 1 <br /> ADDRE <br /> NEAREST CROSS STREET <br /> TRzE. Thu✓�y8�w <br /> wntuk (�RTNUIWP UATEAGEMTT _C_4t� 11u LOCALAGOD 1:1 KDOW..ABDO <br /> CITY NAME I VV ❑ DOUTM <br /> Lo <br /> C.i�-�„f - STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> CA G say o <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PflOCESSOfl ✓BOX It INDIAN EPA ID If <br /> ❑ 1 GASSTATION ❑3 FARM OTHER RESERVATITRUST ON or ❑ - If TANK•s <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE. DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME( //11 �ll CARE OF ADDRESS INFORMATION <br /> ra( LOIL11�f me c-'Novi. GyT TOT-PARTNERSHIP <br /> MAILING or STREET gDDRESS ✓BOxmiOdloate ❑ STATE-AGENCY <br /> 3:r 11 CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME - STAT ZIP CODE PHONE p,WITH AREA CODE <br /> Lod.-;— � Q ��18-4 ao`i L-t(oa vsg 1- <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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 TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION R AGENCY R FACILITY ID If N of TANKS at SITE <br /> E-31 a 1 0 1s1:(:= o 1 0 1 0 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> -:FScLozof <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL7E�D c <br /> Oma. o� "� LA 1 YES C] NO ❑ S l 7l 6 <br /> CHEMO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT III 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 0 Y. <br /> FORM A(3-2-SB) <br /> law DATA PROCESSING COPY <br /> ,"a[( <br />