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. _ a_. _ �. , .Cg � i„cs :qaa,;*�±.;; :-.,fie c���• s•a r , <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': r� M <br /> UNDERGROUND STORAGE (TANK PROGRAM ro , <br /> SITE FACILITY/SITE, INFORMATION and/®r PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cql FO R1P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ®I5 CHANGE OF INFORMATION ❑ ERMANEN LY CLOSED SITE A' <br /> ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑�6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF(ADDRESS INFORMATION j <br /> fie.X C C o Seer CSt-o4 <br /> ADDRESS NEAREST:CROSSSTREET ✓Bo.toiMirste ❑ PARTNER6FtIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ couNTY-AGENGY <br /> CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE + <br /> vi fe e CA lctf 3 3 d 'I ) <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID k! 4 <br /> 0 ❑ ❑ TRUSTyLA DS or ❑ � #of TANKHIS sa s <br /> 1 GAS STATION 3 FARM 5 OTHER 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 1 <br /> "fro . �\\ Gar .(oi A 9,9:3—09 y_ <br /> NIGHTS: NA E(LA ,FIRST) PHONE#WITH AREA CODE NIGHTS: I NAME(LAST,FIRST) PHONE It WITH AREA CODE # <br /> s <br /> I <br /> IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME f CARE OF 1 DDRESS INFORMATION <br /> MAILING or STR ET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY s <br /> ❑ CORPORATION ❑ LOCAL-A(3ENCY ❑ EDERAL-AGENCY <br /> CT ...r 1 ii VV V ElfNDIVIDUAL ❑ COUNTY-AGENCY uh K_ <br /> CITY NAME STATE ZIP CODE PHONE q,WITH AREA CODE <br /> I <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OFIADDRESS INFORMATION <br /> MAILING or STRE ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ' <br /> El11. 1 CORPORATION LOCAL-AGENCY EDERAL-AGENCY <br /> 1 —�5 l�J 13 INDIVIDUAL Q ElCOUNTY-AGENCY � LaFI W ' <br /> CITYIVA iol 1 �l S SC ) !TATE I zlP CODE/ PHONE 9, <br /> AREA <br /> CODE <br /> � f <br /> I <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. ❑ It. n Ill. ❑ <br /> I <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 /> I <br /> I <br /> LOCAL AGENCY USE ONLY \ <br /> COUNTY# JURISDICTION# AGENCY# I FACILITY ID# #of TANKS at SITE <br /> . �T_/lq / 1 <br /> I <br /> CURRENT LOCAL AGENCY FACILITY ID 8 BYI PHONE kWITH AREA CODE <br /> I <br /> PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE <br /> i <br /> LOCACTIION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D TE ILED <br /> ! IS 3' 0 B& V0 I YES NO <br /> CHECK IN PERMIT AMOUNT SURCHARGE AMOUNT FFEECODE RECEIPT k BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-E:8) <br /> FILE COPY <br />