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w4441� <br /> f <br /> STATE OF CALIFORNIA . WATER RESOURCES,CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - n <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FMARK 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 CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE;COMPLETED) " <br /> FACILITY/ ITE NAME n CARE OF ADDRESS INFORMATION <br /> alt I �1�[ .� I.: i �c_-( • c /� rG{ L.CI�, Ic ["(Tn,.(� ) � � C�f �� �1G 1 — � t <br /> ApDRES{,S NEAREST CROSS STREET ✓go to w1ute �PARTNEHSHIP ❑ STATE-AGENCY <br /> ; ❑ coNPORATION r aCAL-AGENCY "❑ rfoERaL-AGRacr <br /> CITY NAME ❑ IIVDIYIOUAI OUN Y-AGENCY <br /> /•1 ` STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> L✓ S l CAQI `�a �I c I�. <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4.PROCESSOR */Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION 3 FARM OTHER TRUSTRESERyLANDS ATION or ❑ rAT <br /> of TANK'a <br /> 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#WITH AREA CODE <br /> o NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WfTH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMIr CARE OF ADDRESS INFORMATION j <br /> LJ ft <br /> Lrr (: r�"� n} r" 14. j�1Ct <br /> MAILING or STREET ADDRESS ✓8ox to indicate (rPARTNERSHIP ❑ STATE-AGENCY <br /> -y_ <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY, f <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE'COMPLETED) <br /> NAME CARE OF ADDRESS{NFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP 'z:, 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> .El INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ! STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 1 <br /> r <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS K <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR SON LEGAL NOTIFICATION AND BILLING: 1. II. Q✓ 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# i FACILITY ID# #of TANKS at SITE t <br /> 71 FT_) k , G Eul <br /> U CU G <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME <br /> �1— —1- �y PHOkE it WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE - <br /> LOCATION CODE CENSUS TRACT r SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED <br /> YES E] NO Cl I <br /> CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY; <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I.FIQR MORE TANK PERMIT FORM 'B'APPLICATIONIS), UNLE THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FORM A(3-2-88) ' - <br /> LOCAL AGENCY'COPY <br />