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STATE OF CALIFORNIA WATER RESOURCES CONTROILROARD <br /> FORM 'A': : <br /> UNDERGROUND STORAGE TANK PROGRAM �^ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I� .wo <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ovNEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ' <br /> ILC��J( NEN7LY CLOSED SITE <br /> ONE ITEM 6� <br /> 2 INTERIM PERMIT � 4 AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE I Q W <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) O <br /> FACILITY/SITE NAME t) <br /> x t CARE OF ADDRESS INFORMATION <br /> jArG I F O l.A�se5 N <br /> ADDRESS /. NEAREST CROSS STREET ✓Ea tOiNica@ 0 PARTNERSHIP 0 STATE AGENCY <br /> 9 �°✓L k14 5,(A <br /> iN(rYo l� CORPORATION 0 LWAL AGENCY 0 FEDERAL AGENCY <br /> CIN NAME AAA 0 INDIVIDUAL 0 COUNTYAGENCY <br /> STATE ZIPCODE SITE PHONE#,WITH AR,EYOOD <br /> 1 R ✓- Z(� -��G 7" 2 <br /> TYPE OF BUSINESSCA <br /> : p DISTRIBUTOR q PROCESSOR ✓BOx if INDIAN EPA ID # <br /> E] I GASSTATION 3 FARM OTHER RESERVATION Cr ❑ N of TANK'S I <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(I-AST,FIRST) PHONE#WITH AREA CODE DAYS NAME(LAST,FIRST( <br /> IIIJ /'C PD ^L O — ���� �C(— Y4PHONE#WITHAREA-4 <br /> NIGHTS: NAME(LAST(,FIRST) PHONE p W H REA co6E NIGHTS. NAME(LAST FIRST) 3 G/ <br /> PHONE#WITH AREA CODE <br /> 541.+'A <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME n <br /> CARE OF ADDRESS INFORMATION <br /> Wlo SC wL <br /> MAILING or STREET ADDRESS ENCY <br /> IL,ICORPORAT <br /> gicale 0 PARTNERSHIP <br /> Cl Q ION ❑ LOCAL-AGENCY ❑ FEOERALO-AGENCY <br /> CITY NAME AL 0 COUNTY-AGENCY <br /> Q / ZIP CODE PHONE N,WITH AREA CODE <br /> S A/ Zf1 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �� L d5 <br /> MAILING or STREET ADDRESS ✓Box to in6icate ❑ PARTNERSHIP <br /> 0 STATE AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL--AGENCY <br /> CITU NAME <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE# WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. III. <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYTI JURISDICTION k AGENCY N FACILITY ID R 0 of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME <br /> �n PHONEM WITH AREA CODE <br /> PERMIT NUMBER <br /> PERMIT/'APPROVAL DATE PER EKPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> /) 3 fDATE FILED <br /> (/ o7 O LU YES [] NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN <br /> 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 /> FORMA(3-2-88) a � <br /> V i <br /> V DATA PROCESSING COPY S <br />