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STATE OF CALIFORN"ItKBOARD °' WATER RESOURCES CONTR z`�•°'°w� �".' FORM `A': �-�='` 'i UNDERGROUND STORAGE TANK PROGRAM =" �p SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE `°��F°ay`" MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P Y ITE 1"' ONE ITEM ❑ 2 INTERIM PER ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE p N 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) OD FACILITY/SITE PAVE - CARE OF DDflESS INFORMATION A A RESS ' NEARE TCBOSS STREET ✓Sorin nOcae ❑ PARTNERSHIP ❑ STATE'AGENOe `1 /'I �� p //5 ❑ WAPoRATION ❑ LOCH.#GENLY LAG 2 S �^^ �/ 1- V ❑ INDMHIIAL ❑ CDUNIY.AGENCY CITY NAME STATE ZIP CODE SITE PHO E N.WITH AREA CODE ( ( cA 1 Z o o� Z3-0&65 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F__1 4 PROCESSOR ✓Box it INDIAN EPA ID a RESERVATION or a of TANK'e ❑ I GAS STATION ❑ 3 FARM Q'ITHER TRUST LANDS ❑ Aj/iQ ATTHISSITE D� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) GAYS: NAME(LASE FIRST /f POHON p WITH AREA CODE DAYS MME(LAST.FIRST) PHO�N TH AREA CODE NINT AME(LAST.FIRST) (/{vn PHON #WITHAREACODE NIGHTS'.(// AME(LAST,FIRST( PHONE#WITH AREA CODE A4 A II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION 3 14 --L oamLG MAILING or STREET ADDRESS ✓80x to indicate 11 PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE T 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: 1. 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 COUNTY a JURISDICTION R AGENCY a FACILITY ID k a of TANKS at SITE 3 I E= I D I a I �l o -T v a lo I & It CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE a WITH AREA CODE C LI Z 7 / 2ah PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT a SUPERVISOR-DIST111CT LODE BUSINESS PLAN FILED DAYS FILED Z, y3 P6 YES NO Aj("!tqom J CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTa 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(3-2-8B) C\'�I� DATA PROCESSING COPY