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�pl OF <br /> STATE OF CALIFORNIA WATER RESOURCES CONTRO�`BOARD �y.•"E° <br /> FORM A: <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION " <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C\.PORN <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION El7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE t <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CAR OF ADDRESS INFORMATION <br /> PnT �, I��a tzo►.� 0 5 2 w . w Sr �2 <br /> LlN <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> %1 ) ''1TM S� ���/ B"NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME �v STATE ZIP CODE SITE PHONE k,WITH AREA DE <br /> iy> CA 95 3 - 3 20 zo <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS or ❑ L AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PH'235 <br /> #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> '1->TL O Ie� !}� L(_I r�M ZCA '�1� <br /> NIGHTS: NAME(LAST,FIRST) P ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> t� _I 4 " s I <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> pup c <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> 4 5 2 W . wtu��-� �� INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STA ZIP CODE PHONE#,WITH AREA CODE <br /> t� {4 `� 53 S `{ <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME }} CARE OF ADDRESS INFORMATION <br /> N <br /> Lk)k <br /> jL <br /> MAILING or STREET ADD ESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> L ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> l � L.�._ ��� Q91NDIVIDUAL ❑ COUNTY-AGENCY <br /> STA <br /> CITY NAME �� ZIP CODE HONE WITH AREA CODE <br /> 3 <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.;� 111.❑ <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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# FACILITY ID# #of TANKS at SITE <br /> EI I 1 10 lo 1 -1 14 FE Llo = <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> LI,S <br /> PERMIT NUMBER =PERMITPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVI ,OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> G3 e)Q / 2- 1 <br /> YES NO ❑ _ZZ CJU' <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# L 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 /> LOCAL AGENCY COPY <br />