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R. <br /> STATE OF CALIFORiNIm MATER RESOURCES CONTROs.BOARD <br /> FORM `A': rT <br /> UNDERGROUND STORAGE TANK PROGRAM ��� �o <br /> �lTE �' j FACILITY/SITE, INFORMATION and/or"RMIT APPLICATION <br /> € (/ COMPLETE THIS FORM FOR EACH ACILITY/SITE Orb R" <br /> MARK ONLY ❑ 1 NEW PERM)T 3 RENEWAL PERMIT E!f5 CHANGE OF INFORMATION ❑7 PERMA LOSEO SITE <br /> ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION&ADDRESS—(MUST BE COMPLETED) <br /> FACILITY/SITE NAME je CARE OF ADDRESS INFORMATION <br /> ADDRESS t1 j� NEAREST CROSS STREET ✓9psloeidr�. ❑ PAASF�SHIP 11STATE Af4 O <br /> CITY NAME STATE ZIP CODE / SITE PHONE K,WITH AREA CODE <br /> CAd7 17 _ $ 3 <br /> $35— %c7� <br /> TYPE OF BUSINESS: S�3 <br /> OR ❑4 PROCESSOR ✓Box U INDIAN EPA ID K 1 d TANK s �} <br /> ❑ 1 GAS STATIM FARM ❑5 OTHER TR LANDS or ❑ IATTHISSITE id <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NW <br /> (LAST,RRST) PHONE 4 WITH AREA CODE DAYS: NAME(t-AST.FIRST) PHONE#WITH AREA CODE <br /> 15 PIP- - 5TeVQ,- — 5-,3 <br /> NIGHTS' NAME(LAST.RRSTJ PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION S ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDMSS' ✓Rez to k lic.W ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE b,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION A ADDRESS—(MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓au€o indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> I CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ASM ADDRM SHOULD BE USED FOR SOTS LEGAL NOTIFICATION AND BILLING: 1. ❑ Il. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY b JURISDICTION ff AQENCY# FACILITY ID S #of TANKS at SITE " <br /> { 0 a P1 <br /> CURRENT LOCAL AGENCY FACILRY'€p APPROVED BY NAPE PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT ERPIRAT*N DATE <br /> LOCATTDN CODE CENSUS TRACT 0 S1✓tPFRYl8pR-DISTRICT CODE BUSINESS PLAN FH ED DATE FILED <br /> y7 7 7— YES NO <br /> CHECK 6 PERMfT AAIpUNT SUACHARCE.AMDUNT FEE CODE RECEIPT# BY: <br /> %THIS FORM MUST SE ACCOMPANIED BY AT LEAST(0)OA 1IORETANx PER ff FORM `®'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORYAT{OH <br /> RM A(3-2-66) <br /> j - <br />