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STA7E OF CALlF0RNlk-_,' WATER RESOURCES CONTROL-J- ARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM r wpm z <br /> SSBI IE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> LAI <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C,�IFp RN,' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMA LOSED SITE F-a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE $v -4 <br /> t - t –4I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) w <br /> FACILINAME l CARE OF ADDRESS INFORMATION1\1 m <br /> oV1 /;Uj I-" <br /> ADDRESS NEAREST ROSS STREET ✓Boz b w ate E,❑:PARTNERSHIP. ❑ STATE-AGENCY <br /> q!g <br /> OVA <br /> �jy ❑ CORPORATION U J(X AL-AGENCY', Q FEDERAL-AGENCY <br /> 1�J 1 VC ❑ INDMDLIAL ❑ COGNTY-AGENCY'- -•. <br /> CITY NAME_ L STATE ZIP CODE SITE PHON #WITH AREA CODE <br /> CA f <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSORFRESE11TIVflTION <br /> INDIAN EPA ID # (�f /^❑ 1 GAS STATION ❑3 FARM 5 OTHER LANDS or ❑ CA "`-' &I 6 tU 13 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#WITH AREA CODE <br /> Ei <br /> -4 Yid, <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM • �} V\to CARE OF ADDRESS INFORMATION <br /> )?a <br /> MAILlfGOSTQIETADDRESO 1 ✓Box to indicate E] PARTNERSHIP ElSTATE-AGENCY <br /> A (�S /// ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> V ��G�1 0 INDIVIDUAL 1-1 COUNTY-AGENCY <br /> CITY�ANE f? <br /> HONE WARE/ O <br /> 0 eLIQ 'M4 `VLI 75F <br /> 111. TANK 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#,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 T E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> ICANT'SME(PRINTED 8 SIGNATURE) DATE / <br /> r I G b A, V 8 g <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [3:[j] [:[ � sI r)-1 EololoLll_ <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> '7 ershwL4 R <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED q <br /> d d O 3 U 3 YES ❑ NO ❑ � —/ <br /> CHECK# PERMIT AMOUNT SURCHARGE 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 INFORlUTION ONLY \ <br /> FORM A(3-2-68) <br /> DATA PROCESSING COPY. , y s <br />