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STATE OF CALIFORNIA <br /> FORM `A': WATER RESOURCES CONTROROARp <br /> SITE UNDERGROUND STORAGE TANK PROGRAM k F <br /> WP \� <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLI - m <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE CATION c ,a � ° y� <br /> MARK ONLY 1 NEW PERMIT "�,FoaN P <br /> ONE ITEM ❑3 RENEWAL PERMIT <br /> 2 INTERIM PERMIT q AMENDED PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> L FACILITY/SITE INFORMATION &ADDRESS- 6 TEMPORARY SITE CLOSURE ' <br /> �G <br /> FAC ILITYis1,,T)yg�\NAME (MUST BE COMPLETED) C7 <br /> �lJt CARE OF ADDRESS INFORMATION 00 <br /> ADDRESS f"a <br /> ��(�T L11L - <br /> V I �I (�,� � NEAREST CROSS STREET <br /> CITY NAME �✓,.�8oxlamdicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> YRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> STATE ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> ZIP DE SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS: �2 DISTRIBUTOR � CA �' S(��� <br /> El4 PROCESSOR -/BO if INDIAN EPA ID # L A-�.J— <br /> 1 GAS STATION 3 FARM RESERVATION or ❑ <br /> OTHER TRUSTLANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) #of 1415 SITE DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON AT THIS SITE <br /> �/ PHONE#WITH AREA CODE (SECONDARY) <br /> l�-�� DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> PHONE k WITH AREA COQE NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — PHONE#WITH AREA CODE <br /> NAME MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> ✓Box to indicate ❑ PARTNERSHIP <br /> CITY NAME ❑ CORPORATION C1LOCAL-AGENCYEl STATE-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY El FEDERAL-AGENCY <br /> STATE ZIP CODE <br /> PHONE#,WITH AREA CODE <br /> I11. TANK OWNER INFORMATION &ADDRESS - ( <br /> NAME MUST BE COMPLETED) <br /> V L%t yi`.,O CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> ✓Box to indicate ❑ PARTNERSHIP <br /> CITY NAME ❑ CORPORATION ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> 11 INDIVIDUAL ❑ ElCOUNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE <br /> PHONE it.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOT.LEGAL NOTIFICATION AND BILLING: I. <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 8 SIGNATURE) CT <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> �^ AGENCY# FACILITY ID# <br /> 3 � #(, of TANKS of SITE <br /> CURRENT LOCAL AGENCY FACILITY 10# 0 R _1 1 -^'-)C EIEI�j <br /> l) o APPROVED BY NAME <br /> �J1 PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# <br /> SUPERVISOR-DISTRICT CODE <br /> �> BUSINESS PLAN FILED <br /> � - DATE FILED <br /> CHECK# PERMIT AMOUNT YES E:1 NO ❑ C'( I <br /> SURCHARGE AMOUNT FEE CODE <br /> RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> IM A(3-2-88) <br /> DATA PROCESSiING COPY • <br />