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STATE OF CALIFORNIP WATER RESOURCES CONTROIROARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE ` FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' y COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 50 W ] C:) 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W FACILITY/SITE NAM �1 CARE OF ADDRESS INFORMATION pp Ed {Y1Ctnu,ei` ADDRESS (� C ' 1 NEAR TCROSS STREET ✓ rovdoa# ❑ PARTNERSHIP Cl STATE AGENCY D`J S. U Fl 1 p () AIN O INWOUkI� O CDLNTYYnc NEC ❑ FEDERAL AGENCY CITY NAME is+OC��r, STATE CA ZI�5 GODE Z0IQ SITE Lilo A.WITH �A CODE # fol TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓ AT Box if INDIAN EPA ID f of RESERVATION or 01 TANN' ❑ 1 GAS STATION [:] 3 FARM OTHER TRUSTLANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE MCGLV_�, a89 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CGCAREOF ADDRESS INFORMATION A MAILING or STREET ADDRESS ✓ ox to Indicate ElPARTNERSHIP ClSTATE-AGENCY O CORPORATION E) LOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME .(-�� STA ZIPq d0 I P;k 0 9WITH�IE�� n� I 5A CODE c..k. \� . ` 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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. 19it. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE ® 0 ® 11 g 5 1 0 1 0 I C) I1 CURRENT LO CA4 AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE (h LL. C� 18 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILECD� yYESE3 NO ❑ 11.2,%t PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: is 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(3-2-88) • S 0 DATA PROCESSING COPY