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-75024--4453 <br /> STAT ` jAlA*4mp` WATER RESOURCESVWW CONTROL BOARD 5, 4 <br /> FORM 'A': MAY 2 1 10'19 UNDERGROUND STORAGE TANK PROGRAM V e <br /> Sl'TNVIRONMffMtL jX(§IffE, INFORMATION and/or PERMIT APPLICATION real <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•a "' yF�/ <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE �y <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �® <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) C > <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 5F-N Hot-.:T- c Z 5 SH�� L— 5MF+ <br /> ADDRESS NEAREST CROSS STREET �✓�bn�&sR ❑ PARTNERSHIP D STATE AGENCY <br /> 3011 W. 3EwjA MIN Homer D7i � 5 L�(DI"EM ON ❑ LGcaAAGNLY ❑ RXR AGENY <br /> 01 Ixoxllwu ❑ LOCAEAACBILv <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> 5TOGKToti, GA Ca -7524-4¢ <br /> TYPE OF BUSINESS: EPA ID N <br /> 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN <br /> RESERVATION or N of TANKS <br /> A ICAs BTATION ❑3FAflM ❑SOTHEfl TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> KENDRICK] J0l4N (3&) 477- 1703 6W-PPA DARLA (209)477-1703 <br /> NIGHTS NAME(LAST,FIRST) H NE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> �CE&IDRIGK� �oFfN (�o9)P 7(p- 1409 5�1EPP1� bPRl�l (9 ) 474- 52 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME SH0CARE OF AD RESS INFORMATI N <br /> HeL_L_ 1 L_ 0-0mF,Qti!'1' SAM� <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O i1 in�f CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> '50X 'TSL ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CAN CORD CA q45 q 415 (D7(n-1414-- <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF AOD ESS INFORMATION <br /> SI�EILL o1 L_ CnnPA� ,l SME <br /> MAILING or STREET ADDRESS ✓moa to indicate ❑ PARTNERSHIP 11STATE-AGENCYp O [ 'Z [CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> �,p/y CCi7 GA RQ5 Z`� ¢15 Col IV. LEGAL LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. 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 B NATURE) :�i,4 DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY N FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> Ln 3a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESSE FILED NO <br /> ❑ DATE-,,7 <br /> / 23 /S 2 /n�(/( — <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N AT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(U OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> A(3-2-88) <br /> �'S� r►' DATA PROCESSING COPY <br />