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) .,.r a ,. ....,.,,.;. ,,.�„�, TPS _u, •�rr.+-'-"^/�; ,.+rP1�'PeE'1!EkF.n.T.. .,;a-;,,,id4 , <br /> j STATE OF CALIFORNb� WATER RESOURCES CONTR�II41OARD / ` �:"• <br /> FORM 'A': °a <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m n <br /> 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑p 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 /> �iL4Et.(, aL� Se�VILE STAnoA{ « <br /> ADDRESS NEAREST CROSS STREET ✓EoxWoftaK ❑ PANINERSHP ❑ STATE-AGM <br /> O ❑ ICDI*mT0N O Lock AGM ❑ FEGEML AGOV <br /> N DUCITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE W <br /> CA 4$"2oq ¢71 17o <br /> TYPE of BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box N INDIAN EPA ID # <br /> 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS AT THIS or M W T.. <br /> ❑ SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST•FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> J. t4W Vg1 CA e_ 7?qo) 4AAe ¢77LvI <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> A- 47614 ovE LOS ¢_74-1 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA CARE OF ADDRESS INFORMATION , <br /> ��6DRlC.I� <br /> MAILING or is <br /> TREET AO RESS ✓Box to indicate 13 PARTNERSHIP 11STATE-AGENCY <br /> U, CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Toc'vTbg CA _ G&_ I q.S?�i o <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMEy CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /j Q CORPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY <br /> �/� B INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPEs0 ef'p-40 <br /> pEAo4� <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS GGQI 8 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ if. ❑ III,0 <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 /> Cres MA4kA-4✓B35 ii-218a <br /> LOCAL AGENCY USE ONLY A4/—,eAJT �orD 5A46Z 6/L Gp, <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> JEEE] <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WRH AREA CODE <br /> F I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> YES NO (/ <br /> CHECK# 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(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FOHM A 19-2-88I <br /> a.. DATA PROCESSING COPY �, <br />