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i ATE OF CALIFORNIA 'ATER RESOURCES CONTROL BOO <br /> )RM 'A': m� <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> ITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ <br /> 1 NEW PERMIT ❑3 RENEIVALPERMR [N 5 CHANGE OF MORMATION ❑7 PBUTANENTLY CLOSED <br /> ONE ITEM [:]2 RfTERIM pERLIR ❑ AMENDED PERMIT E]6 TEMPORARY SITE CL.OSIAIE 7-7 <br /> TACILrTY/SITE INFORMATION&ADDRESS—(MUST BE COMPLETED) <br /> CME OF ADDRESS MFORMATLON <br /> FAGKFTY/SrTE NAME <br /> �c�Co 1ti —CII 3 ✓Babidak ❑ IMMIO ■' ❑ STATE4WO <br /> ADOTI65 _ II^� NEAREST CROSS STREET �IPpKiCN ❑ LOCAL4wa O I✓�OYUfRLT <br /> L./ S Ate[ ( �♦G pUe. - CU 14 ❑ ■OnuVL ❑ NI■RYlCRIfX <br /> STATE ZIPCOOE SIJTEEP"ONEON.WITH AREA CODE <br /> CITY NAME iC(.'% <br /> S �OC� FDv CA <br /> TYPE OF BOSNESS ❑Z DISTRIBUTOR 0(IROCESSOR ✓W NIOIAN EPA■)■ N dTANSI <br /> I GASSTATXNI ❑3 FARM <br /> ❑5 OTHER TRUSTLANDS <br /> « ❑ AT TH5 SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST.FIrwn <br /> PHONE N WITH AREA CODE DAYS NAME RAST.FIST) PHONE WITH AREA CODE <br /> w QJ ak /,}—.2v 5 :L E. r. 1/1��45�koti— y/.SVPTaeLE■wnHu+F,AeooE <br /> NGHM HAW(LIST FIRST) PHONE■NTTH MEA CODE NIGHTS: NAME"V FIRST] <br /> �Xlco�k Ctii M 6e Kf'or goo-991-3cY� E7(XoN (f4m L,Pv- r <br /> PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> = XXot 5 <br /> MAILING IX <br /> GENCY <br /> /-//SSU F%%..``F G..L(?L'1.�e.., l OCT' ✓BO ❑ PARTNERSHIP ❑ STATE- <br /> STREET ADDRESS Q(pRPORATION ❑ LOCAL-AGENCY ❑ FEOETML4GLNK <br /> Y <br /> ❑ CTY-AGENO <br /> PHONE N.WITH AREA CODE <br /> CITY NAME STATE ZIP CODE <br /> f OU5+0.K 7709a <br /> I. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> 8pr b it to [I PARTNERSHIP O STATE-AGENCY <br /> MAILNIG IX STREET{ADDRESS RPORAC»R TION Cl LOCAL-AGENCY Cl FCBERAL-AGENCY <br /> SSU {✓CI GGIW�-�'�-1 1 t. OINONIWAL ❑ COlM1Y-AGEfJ(.Y <br /> STATE ZIP CODE PHONE Y.WITH AREA CODE <br /> CRY NAME <br /> 1. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING W HICN ABOVE ADDIIEBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BIW NG: L ❑ IL KL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, <br /> T BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. <br /> DATE <br /> APPLiG/.NJ I�Ig1.�F 1Pt�IT�ED�$l.V .R <br /> ANALYST /3 yo <br /> LOCAL AGENCY <br /> JU I■SVE ONLY <br /> U (V` I <br /> AGENCY N VV FACILITY ID N N al TANKS NL SITE <br /> COUNTY N JURISDICTION <br /> Cl1IiftENT LOCAL AGENCY FACILITY ID <br /> APPROVED BY NAME PHONE N WITN,RFA CODE <br /> /? L <br /> PERMIT E%PIRATION <br /> PERMIT NUMBEfl <br /> PERMIT APPROVAL DATE DATE <br /> DATE FIL <br /> LOCATION CODE CENSUS TRACT, SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED NG ❑ a, 7 ` <br /> � <711� /�' /T YES [, <br /> Z-7 Z '-�, RECEIPT, B <br /> CHECK, PERMIT AMOUNT SURCHARGE AMO NT PECCODE <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK pERWT FORM'B' APPUCATIOfNSL UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY.. \ <br /> FORM AI3-2,81 1 DATA PRONGCOPY 2 LOCALAGENCYCOPY 3 FILECOPY <br /> �� - � C\ �/ <br />