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- <br /> SEA by Ok,,'•rhF <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROLd'OARD h <br /> FORM 'Aii <br /> UNDERGROUND STORAGE TANK PROGRAM `� r <br /> SITE, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> al COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 1?15 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I ' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY SITE NAME CARE OF ADDRESS INFORMATION <br /> �A MmeRsvi-LL E ._9Hi _ <br /> ADDRESS 1 J NEAREST CROSS STREET ✓i to indicate Cl P IF <br /> ❑ STATE-AGENCY <br /> E 5jO„ ` [,_� GI! ❑ CORPORATION ❑-COL-�NCY ❑ FEDERAL-AGENCY <br /> 'v �1 S ❑ INDTANAL Cl COUNTY-AGENCY <br /> CIN NAME STATE ZiP DE_ SITE PHONE#,WITH AREA CODE <br /> I � 1C`T' CA7tQ YDS �J13 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR .❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a �I-t �nOp� 4 SZ� #of TANK's }� <br /> ❑ ) GAS STATION ❑ 3 FARM THER TRUST RESERVATION <br /> A DS ar ❑ �I r� AT THIS SITE * `, f <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 /> OLDS I IAC—Q CSI ) Z,j5 01 ? <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST;FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP .❑ STATE-AGENCY <br /> ❑ CORPORATiON ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE 9,WITH AREA CODE <br /> Ill, TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATF-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <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. II. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,JS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> f <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> F7`1� :10 `7 G1 -411, <br /> CURRENT LOCrAL AGEN=CtY FACILITY ID/ APPROVED BY NAME PHONE N WITH AREA CODE <br /> it I�_k C }l <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT ) SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEFILED.VC / �� I YES NO7 } <br /> I- CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Die: <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 /> `� . LOCAL AGENCY COPY �� <br />