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STATE OF CALIFORNbre WATER RESOURCES CONTROWISOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �o �, SITE FACILITY/SITE, INFORMATION and/or PERMI -APPLICATION o< l o COMPLETE THIS FORM FOR EACH FACI /SITE MARK ONLY F71 1 NEW PERMIT ❑3 RENEWAL PERMIT ANGE OF INFORMATION ❑ 7 SERMA44TILY CLOSED SITE r ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / d�p 1. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) to FACILITYISITE NAME ^ CAREOFADDRESS INFORMATION ADDRESSNEAREST CR �� //�C OSS STREET 64� _ ✓Ba loi FILOCA- 313 ❑ f*W.-ENLY W u Q /j/= ❑ au ❑ PAMNE IF ❑ STATEAAGErac omodu ❑ COUNrr-ncDICY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CO E S71"� CA 'FF16 G o — 7 l 7 TYPE OF BUSINESS: ❑ 2 D BU10R ❑4 PROCESSOR ✓Box#INDIAN EPA ID# If of TANKs RESERVATION or AT THIS SITE ❑ 1 GAS STATION fAflM ❑5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE G �!I NIGHT : NAME(LAST,F T) PHONE N ITH AREA C DE NIGHT& NAME(LAST.FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Ll L AJ m A . MAILING or STREET ADD' S t ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Nd I N ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME 7 STATE ZIP COl S-:mL'I PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME ^ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicete ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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: L ❑ IE ❑ IS.❑ 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 L OCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY M CILITY ID N Mol TANKS AI SITE CURRENT m CY FACILITY IDN APPROVED BY NAME PHONE If WITH AREA PERMIT NUMBER PER EXPIRATION DATE LOCATION CODE CENSUS TIIAC�M SUPERVISOR-DISTRICT CODE BUSINESSP SN FILED NO ❑ DATELEDD CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. FORM A(3-2-B8) "Naw DATA PROCESSING COPY .�.