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STATE OF CALIFORNIP WATER RESOURCES CONTROPIOARD yro ."•� <br /> FORMW: <br /> : UNDERGROUND STORAGE TANK PROGRAM <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE "`'FoR"%" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSUREr <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) I <br /> FACI TY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r <br /> ADDRESS NEAREST CROSS STREET ✓BmI< indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> yy�/ <br /> El CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY CTIr <br /> ' PC C �/'C, o Cp . �� // ❑ INDIVIDUAL ❑ COUNTY-AGENCY LLk <br /> CITY NAME STATE ZIP ODE SITE PHONE#,WITH AREA CODE <br /> 54-o C- CA 07 oZ0q If 73 -/1X7"7 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F__] 4 PROCESSOR ✓Box if INDIAN EPA ID 01 RESEJIf y1 <br /> i <br /> GAS STATION ❑3 FARM E] 5 OTHER TRUSTVLANDS ATION or ❑ ,✓ 0/ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> L �"1 LL ao9 "3-U77 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,fir t uAl tt- <br /> MAILING or STREET ADDRES ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 5 c��I El11CORPORATION El <br /> lLOCAL-AGENCY ElF DRAL-AGENCY <br /> ctdoeu INDIVIDUAL COUNTY-AGENCY '1� <br /> CITY NAME v STATE ZIP CODE ' <br /> ONE#,WITH AREA CODE <br /> S- /4 5�o aO - /a o <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> sarn ,e as 4QPppertowylev, <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> [7 <br /> CITY NAME STATE ZIP CODE PHONE#,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. 11. 0 II1.❑ <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 /> F <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> / � 0 1 D a � <br /> AGENCY FACILITY IIDD# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACTT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 31 OD YES NO OPERMIT AMOUNT SURCHA GE 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 />