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STATE OF CALIFORNI/1 WATER RESOURCES CONTROL .,OARD <br /> FORM `A': t, <br /> UNDERGROUND STORAGE TANK PROGRAM W � � M1�m <br /> SITEI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c'L,Fs.R_p" <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY 7 CL <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> W <br /> FACILITY/SI E NAME CARE OF DDRESS INFORMATION <br /> ADDRESS NEAREST CROSS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> f G C- INDIVIDUAL ❑ COUNTY-AGENCY <br /> -AGENCY 0 LOCAL ❑ FEDERAL AGENCY <br /> CITY NAME, STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> L dil CA 4'6 ztia 26R- -- J1 0 <br /> TYPE of BUSINESS: ❑ 2 DISTRIBUTOR F-1 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> 1 GAS STATION 1:13 FARM ❑ 5 OTHER TRUST LANDS ❑ 6 A L�0�0 3-,�&Z- AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: N ME(LAST FIRST) PHONE#WITH AREA CODE <br /> is - 11Z ,3 r -0-462--1301 <br /> NIGHTS: AME(LASt,FIRS4 PHONE#WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I1. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF 0ADDRESS INFORMATION <br /> o T,14- a( r /V03Ckp� <br /> MAILING or STREET ADDRESS ✓Box to indicate PARTNERSHIP ElSTATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL El COUNTY-AGENCY <br /> CITY NA STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 22 0 1 -213- Y488 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> kitB-x, Yn a 304)(a <br /> MAILING or STREET ADDRESS ,,✓/Box to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> X—CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> llJ 1 rV s �'1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NA STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 7207 1 �3 z�3� SySa <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. if. ❑ 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 /> De F Kb S- 713-- 89 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 1 j 6 1000 <br /> URR�Ey, <br /> NT LOCAL AGENCY FACILITY ID# APPROVED BY NA PHONE#WITH AREA CODE <br /> PERMIT NUMBERRMIT APPROVAL DATE MIT EXPIRII I N DATE <br /> PE <br /> LOCATION CODE CENSUS TRACT# SUPER ISOR-DISTRICT CODE BUSINESS PLAN FILED IDA#FILED <br /> D7 ��, YES NO e -)/ <br /> CHECK# PERMIT AMOUNT SURCHAR E AMOUNT FEE CODE RECEIPT# 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 />