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STATE OF CALIFORNk,, WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 0 ff <br /> COMPLETE THIS FORM FOR EACH FY/SITE <br /> 4 . <br /> PMARK ONLY N PERMIT Fl 3 RENEWAL PERMIT AfVCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACLITY/SITE NAME CARE OF ADIDANFORMATION <br /> ?!�( &Lq?Lv_ — <br /> ADDRESS NEAREST CROSS STRQ/T !�8pW<d._ie 0 PARTNERSHIP [-I STATE-AGENCY <br /> 4o INDI <br /> ORVIDUAL PORATION El COUNTY AGENCY El 0 LOCAL-AGENCY FEDERAL-AGENCY 00 <br /> r <br /> CITY NAME STATE ZIP CODE SI PllNE 1,WITH AREA CODE <br /> CA <br /> TYPE SINESS F__] 2 DISTRIBUTOR F—] 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> OFTRUST <br /> S 0'if I #of TANK's <br /> 7RESERVLATION or F--1 <br /> 5 OTHER T U ST LANDS AT THIS SITE <br /> TYPE <br /> STATION [:] ❑3 FARM TRUST LA <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> - -ww <br /> NIGHTS: N (LAST,FAST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FI ST) .7 / PHONE H WITH AREA CODE <br /> 1 <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓E3 indicate 1:1 PARTNERSHIP El STATE-AGENCY <br /> P0, I FEDERAL <br /> ORP RAT,ON 0 LOCAL-AGENCY E -AGENCY <br /> cf0 1 , <br /> . _-74�lelal KINDIVIODUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> S Q71 Ill?v() <br /> Ill. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓_a9,ndicate 1:3 PARTNERSHIP 0 STATE-AGENCY <br /> L-r-CORPORATION El LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL El COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <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. E if. El Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> IAPPLICANT'S <br /> NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> ICOUNTY'# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> KCII I I I I D to_ I a I /I V_ vl.�l LO 10 10 1�1 <br /> C71kill..AGENCY_EACILITY ID# APPROVED B NAM CURRENT LO Y PHONE#WITH AREA CODE <br /> —17 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PKIMIT EXPIRATION DATE <br /> LOCATION C )E CENSUS TRACT# SUPERVISOR-61STRICT CODE BUSINESS PLAN FILED ❑ DATILED <br /> k7/ <br /> -I I YES E] NO <br /> ,23- 0 —7--cll—/ -,)- g2- <br /> CHECK# PERMIT AMOUNT SURCHARGE Am6UNT TEE CODE RECEIPT# BY: F <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 C <br /> FORM A(3-2-86) <br /> DATA PROCESSING COPY <br />