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SGY, QOQG,, n <br /> U <br /> ry IFORNIA ONTROL BOARD <br /> s <br /> UNDERGRO ,� <br /> K PROGRAM <br /> 5��� 2 1n�� FACILITY/SITE, INFORMAIKON2aAWY& PERMIT APPLICATION <br /> ft•i <br /> ENV NMENTAL�'IE1=A—yL COMP I,9�"tf°�',�AP��'lQ�kin/SITE <br /> E�Ii�41 bPh r ALJ 1 NEW PERMIT ❑ 3 RENE�DEq'iqyjtT I�ElANGEOF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ONE ITEM u❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 10 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> o „ <br /> ;><><<';><><<' S -7-01 6 C"NE REST CROSS STREET ✓Rm loifiI D PARTNERSHIP D STATEAGENCY F. <br /> AD ESS ❑ G01'NWT& D LCGALAGENCY D FEDERAL AGENCY N <br /> Y2 ,5" CcG - G. v D U. 'a s D INDWIMAL D COUNTY AGENCY r <br /> CITY NAM STATE ZIP CODE SITE PHONE M.WITH AREA CODE <br /> ��ack { dr CA �S207 209 -5;51 <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID 0 B of TANK's <br /> ❑ ❑ 5 OTHER RESERVATION or ❑ pT THIS SITE <br /> 1 GAS STATION ❑ 3 FARM ❑ TRUSTLANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST)- PHONE M WITH AREA CODE DAYS NA E(LAST,FIRST) _ PHONE p WITH AREA CODE <br /> P/ `fO�R I �L S Zy6 k7�D servo✓ ��, 1 S z Y6 47F Z <br /> NIGHTjS_ N ME(LAS .FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRSTI PHONE N WITH AREA CODE <br /> N ME(LA far den+e� - Sz'36Y9 �G en L+ h1 eeA l e i (Jd-S9 <br /> H. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> I NAME <br /> X 1 ✓Box la indicle PARTNERSHIP <br /> D STATE-AGENCY <br /> MAI or STREET ADDRESS D FEDERAL-AGENCY <br /> n ❑ CORPORATION 3 � ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> S (GZIP CODE 2 a PHONE p,WITH AREA CODE <br /> CITY NAME .(- C/ <br /> S 1 6 C � ✓! <br /> ii III. TANK OWNER INFORMATION &nnnADDRESS — (MUST BE COMPLETED) <br /> IIS NAME // CARE OF ADDRESS INFORMATION <br /> II MAILING or STREET AO RESS ✓� gox loinoicale [I PARTNERSHIP ElSTATE-AGENCY <br /> f _� B'CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> CO{ U / D INDIVIDUAL D COUNTY-AGENCY <br /> N ME STAT- ZIP CODE PHONE N.WITH AREA CODE <br /> CITY <br /> ouS�dn C '77A Z d 92-3GY7 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> I! 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,ANDjrO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) j' DATE <br /> i1. <br /> J. MEYER- 7 9 90 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION R AGENCY R FACILITY ID k Bol TANKS at SITE <br /> m <br /> CURRENT LOCAL AGENCY FACILITY ID B <br /> APPROVED BY NAME PHONE A WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DAT! PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED <br /> DATE FILED <br /> YES NO <br /> CHECK♦ PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEO'—'1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />