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STATE OF CALIFORNIO WATER RESOURCES CONTROL BOARD <br /> WP: \SA <br /> FORM `A': ' <br /> UNDERGROUND STORAGE TANK PROGRAM =�° � = f M1 o <br /> WE, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <; 1a <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE C9�r.FOR_!\P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> 00 <br /> FAC ITY/SITE NAME m- rG CARE OF ADDRESS INFORMATION <br /> 1 <br /> ADD R SS I NEAREST CROSS STREET ✓ toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> O i✓VV ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMES ATE ZI ODE PEPHO #,WIT REA CODE U <br /> c�+oCi CA 3 -- 7 <br /> TYPE 0 BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION or ,� , n #of TANK's <br /> I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ r1 �AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DA NAME(LAST,FIRST) ^/SPH NE#WITH <br /> , AREA CODE DAYS. <br /> NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> r V ( :L �U <br /> NIGHTS: NAME(LAST,FIRS14 PH NE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> Mercedes. Ac a_ <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> m ec.e S C o sy-cle, <br /> MAILIyG or STREET ADDRESS ✓Box to i cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / <br /> EJ RATION El ❑ FEDERAL-AGENCY <br /> /O O <br /> IVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,W TH A CODE <br /> S C/3 I C) - S9� <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [1:� I I 1 -1 El I I 10 10161:713161 0 <br /> [%- <br /> CUIR)N LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> S � <br /> PERMIT NUM ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA ION CODE CENSUS TRACT At SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED J <br /> a . 2-D a 2J, YES NOE:) (0 � U <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE __TRECEIPT# B . <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) _ <br /> DATA PROCESSING COPY <br />