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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r � <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS ,� <br /> Le7 C? Q �''i1Fap 'COMPLETE THIS FORM FOR EACH FACILITY/SITE V/J �/l� <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANEN;6Y-C LQ D SITE <br /> MARK ONLY ❑ NEW PERMIT 1 <br /> ONE ITEM F-12 INTERIM PERMIT 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITENAE 5 ' <br /> C - *`$ ✓Sozmndcale ❑ PARTNERSFIP ❑ STATE-AGENCY <br /> NEAREST CROSS STREET ❑ CORPORATION ❑ Lom.AGENCY ❑ FEDERAL-AGFNCY <br /> ADDRESS <br /> /D CA oe '�' c f�/V . Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE SITE PHONE#,WITH AREA C/ODE <br /> CITY NAME `.A �.. 5 `?-7 / 6(22 �J' — L���G3 <br /> r ` EPA ID# c� #al TANK's <br /> TYPE OF BUSINESS: p DISTRIBUT R 4�4ROCESSOR ✓Box rf INDIAN N��(/ AT THIS SITE <br /> RESERVATION or <br /> E] 1 GAS STATION ❑3 FARM d5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST} / PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE. <br /> 'g-,/' f�29rt �rHON E N WITH AREA E NIGHTS: NAME(LAST,FIRST) EA PHONE#WITH ARF <br /> NIGHTS: NAME(LAST,FIRST) PHONCOD <br /> IL PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME / <br /> Gr €i /C. SC Cr/ 1 <br /> MAILING or STREET ADDRESS <br /> Cr 7 /�/�`�F.�70.,)C/�'-�i' CORPORATION ❑x-io indicate [I LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> i ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> /f STATE ZIP CODE �;y�4��C� <br /> ONE#,WITH AREA GORE <br /> CITY NAME // CI �/ �:; 3 5 C; 3Uo <br /> C� /7 PI rYT <br /> III. TANK OWNER INFORMA ION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME _ /]L <br /> 1 <br /> MAILING or STREET ADDRESS -w/Box to i RATI e ❑ PARTNERSHIP ❑ STATFFEDERAL-AGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <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: 1. 10, 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# #at TANKS at SITE: <br /> 3 `/ lo I o I o I v/ ld o I v v o <br /> r CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE <br /> lex I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CE�NSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ✓3 (.?3 O 3 a Y YES ❑ NO ❑ <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(l)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) t 1� <br /> FILE COPY <br />