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i STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD SE� rhf V i FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u j SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m �� o COMPLETE THIS FORM FOR EACH FACILITY/SITE �""°°-"-'" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT LTJ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE r ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE gi7W I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W FACILITY/ ITE NAME CARF OF ADDRESS INFORMATION i� e Su . R PrRom 0110 ADDRESS NEARCSI URO SS STREET ❑ PNIINMW ❑ STATE AGENCY -U CQ9PW110N ❑ LOCAL AGDO ❑ FEOEALL AGENCY AJ D INDMOWL D 03UNIY AGENCY CITY NAME STATEE,T,G�.,, SITE PHONE N.WITH AREA CODE w N CA W O?- -FOV TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓So%it INDIAN EPA ID N RESERVATION or M of TANK'F ❑ I GASBTATION ❑ 3 FARM W-1 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIR I PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE - 2 _ - NIGHTS: AME(LAST,FIRST) ONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE aw R e 2 - — 11. PRO ERTY OWNER INF RMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION SO E A'S MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME A� CARE OF ADDRESS INFORMATION SAS 1 MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 69 it. ❑ III.❑ 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 LOCAL AGENCY USE ONLY CCO /^OUTNTYY## JURISDICTION R AGENCY# FACILITY ID R #of TANKS at SITE 01 1010101o , CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WRH AREA CODE F91 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Lnr..,nNCODE I CENSUSTTRRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 23F S� YES NO � CZ/ / LQ _..nN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE FF NO BY: ITHIS 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. FORMA(3-2-88) �"'F DATA PROCESSING COPY