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STATE OF CALIFORNIA WATER RESOURCES CONTROL. BOARD:! EPS. .. T... f y.' •tui "• hF , WP. '•�A FORM 'A': W :1 m UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I� oa COMPLETE THIS FORM FOR EACH FACILITY/SITE C\PORN P MARK ONLY Yl NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION❑ 7 PERMA NTLY LOSED SITE (_& ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ©� N rn I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) OID a) FACILITY/SITE NAME Q CARE OF ADDRESS INFORMATION CARE OF DDRESS INFORMATION ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY # of TANKS at SITE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY I I 1 -1 ❑ INDIVIDUAL ❑ COUNTY -AGENCY ADDRES STATE NEAREST CRO S BEET ✓Box to indicate ❑ PARTNERSHIP F-1STATE-AGENCY ❑ CORPORATION 13LOCAL-AGENCYFEDERAL-A NCY zjc ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME c STATCA ZIP COD PER EXPIRATION DATE PHHD 4. WITH AREA CODE LODI((�kzoq) R LA21 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR */Box if INDIAN EPA ID If SUPE VISOR -DISTRICT CODE BUSINESS PLAN FILED 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESE02 TRUSTVATION LANDS of ❑ /%—,) 1A AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST)PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE 4 WITH AREA CODE h2 0 76 BY. NIGHTS: NAME (LAST, FIRST) PHONE it WITH AREA CODE NIGHTS: ME (LAST, FIRST) PHONE # WITH AREA CODE A �A �A II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF DR ESS INFORMATION STRE E/ Illox to indicate Cl PARTNERSHIP ❑ STATE -AGENCY CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY STATE I ZIP CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME 51A ff-A� CARE OF ADDRESS INFORMATION MAILI G o, STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY # of TANKS at SITE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY I I 1 -1 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE I nCel A('FNCY IJSF ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE [JR] I I 1 -1 EI I I I bD1:5 ©bo FLI LOC L AGENCY FACILITY ID # APPROVED BY NA PHONE 0 WITH AREA CODE zjc PERMIT NUMBER PERMIT APPROVAL ATE PER EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUPE VISOR -DISTRICT CODE BUSINESS PLAN FILED RDAT�ILED �GJ 6 YES NO CHECK # PERMIT AMOUNT SURCHA G AMOUNT FEE CODE RECEIPT # BY. 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. ORM A (3-2-88) \ DATA PROCESSING COPY S