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E T/� 1 r'� .•o rte•. <br /> STATE AT 0i^ �rAV FOl!^'� <br /> �,� WATER RESOIl�RCF=S COR)'T• � BOARD <br /> FORM `A': : <br /> UNDERGROd N.n— STORAGE TANK PROGRAM 7 <br /> ,:,ITE FACILITY/SITE', INFORN1,ATION anti/or PERMIT APPLICATION <br /> COMPLETE THIS FOR!tR FOR EACH FACILITY/SITE <br /> MAIRK O!YLY ❑ t NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CH"','GE OF INFORMATION I 7 PERMANENTLY CLOSF7 S1 L <br /> ONE ITrMl ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILIT`.'/SFTE INFO:?MATION & AD'-jRFSS — (MUST RE CONIDLFTM) t <br /> FACILITPL 51TE NAME CARE-Of ADDRES'S INFOHMAIIUN <br /> ADDRESS �j ' ' I NEAREST ROSS STREET ✓& r Oral¢ ❑ PARTNER`;HIP ❑ STATE AGE" <br /> + 1/�/I 0 v wot `�{ J^� U INOVADHA'ION ❑ WUNTY-AGIN ❑ fEDERA:AL'NCY <br /> Yyy 111[[[ ( 1 C/: Y l`(/ ❑ akO ,RAL ❑ LOX-AGENCY <br /> CITY NAM STATE IIP CODE SITE PHON # WIT H AREA CODE <br /> TYPE OF BUSINESS: C•1 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bvx if INDIAN EPA I!? #hh %� f� / <br /> ❑ t GAS STATION ❑3 FARM 5 OTHER <br /> RESERVATION <br /> or ❑ (..�'1 "�� V I AT THIS SITE ' <br /> ! EMERGENCY C'ONTA^..T PERSON(PRIMARY) EMERGENCY CONT/'.CT PERSON fSECONDARY) � <br /> DAYS:NAME(LAST,FIRST) PHONF it WITH ARLA COOT OAY,i. N!'AL(LASI E!RSl) PRONE#WITH AREA CUJE <br /> riSl�l�°14 106`�� a <br /> I� NIGHTS: NAME(LAST,FIRST) PHONE#WITH AHEA L.(_0F NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> i <br /> !F. PROPERTY OWNER INFOPMATION & ADDRESS— f!k"'UCT COMPLETED) <br /> NAM�� �� C',RE OF ADORE INFOFIMATION <br /> me)� <br /> —_ <br /> MAILI(JG �r STET ADDRESS Q ( ✓Box to indicate C1 PARTNERSHIP ❑ STATE-AGENCY <br /> +! O��i( ❑ CrRPORATION ❑ LOCAL•AGENCY ElfEUERAL-AGENCY <br /> (.4 D INf tW DUAL ❑ COUNTY i.:_NCY <br /> CITY YF n ST tiL ZIP Or• #rHONC WITH ARE CODE <br /> EA 20 7� <br /> \"Pll. TANK OW?OER INFORMATION A A 0DRF1,S — (MUST 3E COMPLETED) <br /> Nnh'E - CARE OF nUDFI":':S INFORMATION <br /> so,vi lel <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGEi <br /> ❑ GORPORAIION ❑ LOCAL-AGENCY ❑ FLUERAL-AGENCY <br /> ❑ INEIIVIUUAL ❑_ COUNTY-AGENCY <br /> -OUNTYAGENtCY <br /> CITY NAME STATEr <br /> ODE I PHONE#,WIT H AREA CODE <br /> IV. LEGAL F'nTIFICATIO ': AND, ^"LLING ADDP.-ESC FF----1I <br /> FrHECK ORF(1)BOX INDICATING WRICH AF30YE ADnPE SS SHOULD BE USED FOR-tCTH LEGAL NOTI-ICATION/.ND BILLING: 1. E] it. ❑ III.7L <br /> THIS FOR///M HA+.3 BEEN COM,PL UNDER PENAL 7Y OF PERJURY,AND T T <br /> �� E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> II M <br /> Q I�NAME GNP.1 VDALE <br /> '.'") t <br /> �t wtict U1 /� 1f� 3 <br /> LOCA!AGENCY USE ONLY <br /> n�eas+�-a•v.^+.ye-.:-.r .aerssr.-.,-t.:rn._... .. .. .., .... .. .. <br /> COUKTY# JURISDICTION# AGENCY# FACILITY ID#( #r i TANKS at SITE <br /> it <br /> CU'+PENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH.AREA CODE <br /> PERMIT NUYIER -t:'IMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODS CEKSUS TRACT O SUPERVISOR-DISTRICT CODE P1ISINEP'?­_'N FILED DATE FILED <br /> YES NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE P-CEIPT N BY: <br /> j THIS FOR""!!.ST` .''"'T)".<?ANIED BY AT LE.i.-�i(1)OF k`Ct'-?i=TANK 1�I RY:T F `' W APPLICat `--;, L :E:S5 THi5 ISA CHANGE OF S, E!a'ORMATIO!:ONLY. <br /> FORM A 13 2-aA) <br /> DATA PROCESSING Ci <br />