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STATE OF CALIFORNIL WATER RESOURCESCONTRO. JARD J <br /> �1 <br /> 4 i <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> X ICS NONE N <br /> ADDRESS' I NEAREST CROSS STREET ✓Boye(�q,[eW ❑ PARTNERSHIP ❑ STATE AGENM 00 <br /> "1 I I E ORPORATION ❑ LOCk AGENOY ❑ FFDEDLAGENCY <br /> Q ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> -TnNI CA 4 (209 5 —(n <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA 10 p <br /> RESERVATION or #of TANK'a <br /> ❑ 1 GASSTATION ❑3 FARM ❑ 50THER TRUST LANDS ❑ ATTHISSITE3 <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 /> /1 EL[.r�° �j2AC6 Z 9S -Lo 51 J' i Q_u_I 1-541-m �15�9i15 -1005 Z <br /> NIGHTS: NAME(LAST,FIRST) PHONE IT WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> �X [ o <br /> MAILING or STREET ADDRESS ✓$#x to indicate El PARTNERSHIP 11STATE-AGENCY <br /> CORPORATION 11L-AGENCY 13FEDEHAL-AGENCY <br /> l L N 3 �LOIO ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 1VOL;5 Did _D495 O -3 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMED CARE OF ADDRESS INFORMATION <br /> l� <br /> MAILING or STREET ADDRESS ✓Box tointlicate 11PARTNERSHIP ❑ STATE-AGENCY <br /> 55o l rC(F INDIVI DUAL oRPORATION El COUNTY-AGENCY CY El LOCAL-AGENCY 11 FEDERAL-AGENCY <br /> Yj <br /> CITY NAMESTATE ZIP CODE PHONE#,WITH AREA CODE <br /> To <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 If #of TANKS at SITE <br /> ® = = 10101IT2= 060 -3 <br /> CURB T LOCAL AGENCCYY,FA LITY ID# APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRA�CC�TT//O\ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT GFILED <br /> Dl oa D� / YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGEAMOUNT 7EI <br /> RECEIPT Ar 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />