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STATE OF CALIFORNIV WATER RESOURCES CONTRANIOARD t'"°" <br /> I , °ml � <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT MXHANGE 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 /> lzz�w `7`7 E7-,4at dDecker- Mal1 ) <br /> ADDRESS ` n NEAREST CROSS STREET ✓ aminle ❑ PARTNERSHIP ❑ STATE REDO <br /> O J UC 40" ❑ womHUAi� O LW(NlNYAACENGY ❑ ROFAAI AGENIX <br /> CITY NAME STATE ZIP C DE SITE PHONE#,WITH AREA CODE <br /> <Vfvckt ep-j CA 42,d 207 S- / <br /> TYPE OF BUSINESS'. ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID k <br /> RESERVATION or � qqpp #oI TANKS <br /> ❑ I GAS STATION ❑3 FARM BOTHER TRUST LAI 5 ❑ �Qyv� 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 If WITH AREA CODE <br /> eckwa j jd�,,a 'Ifs -3 -06f� aWe- <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST, IRST) PHONE#WITH AREA CODE <br /> u <0 at, <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME -F CARE OF ADDRESS INFORMATION <br /> ES Gtlt 2 c G4 ! Cxe �N c��4N <br /> MAILING or STREET ADD ESSA/. ✓Box tolnEicate El11PAR NERSHIP ❑ STATE-AGENCY <br /> 5� 0� 1 !r 2'-� 11CI❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STATEZIP DE PHONE#,WITH AREA CODE <br /> rr�r CtyYje Gd �yn/0 -�e -46 <br /> III. TANK OW ER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME nn CARE OF ADDRESS INFORMATION <br /> Q7 <br /> MAILING or STREET ADDRESS ✓Box to inEicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,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. ❑ ILaIII. ❑ <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 At AGENCY# FACILITY ID# IF of TANKS at SITE <br /> 7 - c,b I / E= 10id 10 <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOCATIONCODE CENSUS TRACT M SUPERVISOR-0ISTRICT CODE BUSINESSPLAN FILED DAT FIL D <br /> QD 2 YES NO /��PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-SS) 10 <br /> DATA PROCESSING COPY <br />