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_ _ _ � m <br /> STATE OF CALIFORA WATER RESOURCES CONTR11BOARD ":°"' `"A <br /> UNDERGROUND STORAGE TANK PROGRAM =" �" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �"�-'�sa-"-'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION [?-,-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) II <br /> 4 <br /> FACILITY/SITE NAME CARE F ADDRESS INFORMAT N <br /> ADDRESS NEASTCROSS REET ✓Baclairdxak 11 PARTNERSHIP El STATE AGENCY <br /> A➢ON EI M^ ` L/ $fIJAPOALOCAL ❑ FEDERAL AGENCY <br /> J- 1 ' ISI ✓1 V.nC�..(�lD (.tom. ❑ INDIVIDUAL ❑ wuxn,AcENa <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA M^F <br /> S4- CA q5� o �o X09 <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> RESERVATION or - #of TANK'a 0/, <br /> ❑ 1 GASSTATION [:]3 FARM �OTNER TRUST LANDS ��— AT THIS SITE V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LABT,pIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> NIGHTS: NA E(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> R-mw <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMEp CARE OF ADDRESS INFORMATION <br /> 0�.� ry 0C?� j C-CO' s1-tA r <br /> MAILING Vw,l5TREET ADDRESS I/BOx t0 indicate 13 PARTNERSHIP ❑ STATE-AGENCY <br /> 1 it <br /> .,a_CORPORATION 11LOCAL-AGENCY 11FEDERAL-AGENCY <br /> 0 <br /> 1 QJ �x ` ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME /) STA P%4( PHONE N.WITH <br /> _Yj <br /> III. TANK OWNER INFORMATIO(\N &ADDRESS — (MUST BE COMPLETED) S h19 <br /> NAME � nn CARE OF ADDRESS INFORMATION <br /> l� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ II. If. ❑ <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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# Al of TANKS at SITE <br /> ® = = lololthl -1191d c <br /> CURRENT LOCAL AGENCY FACILITY IDl# APPROVED BY NAME PHONE#WITH AREA CODE <br /> R <br /> PERMIT NUMBER PERMIT APPROVAL DATELIEE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CO CENSATRACT!)i# SUPERVISOR-DISTRICTBUSINES,PSNFILED NO <br /> ❑ DATE FILED I I 9 U- <br /> CHECK#(j`U`�J\ PERMIT AMMOU`CjN]TT SURCHA'R`G-EI/A^MMOUNNTJ, ODE RECEIPT# CC IIBBY:/1 <br /> A ITHIS 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 /> FORM A(3-2-881 <br /> 0 DATA PROCESSING COPY 0 <br />