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.. �-..q-" rcrT-a.-a ••v-•• -r.;'�#"."'•�"°n-a.°'nq", r.eJ6'�Pg"�d.`':vi'7��'r�(''f�'AI!TW"yy'!I�>t�`..cx ,+g, STATE OF CALIFORN14., WATER RESOURCES CONTROLII�ARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =°` o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o G COMPLETE THIS FORM FOR EACH FACILITY/SITE oax r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1—► ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) (1) FACILITY/SITE NAME CARE OF ADDRESS INFORMATI N ADDRESS ��?? NEAREST CROSS STREET offlu ❑ PAfITNBISMP ❑ STATE AGENCY ✓✓�� YY CORPN110N ❑ LOCALAGBY O FEI AGY MU ❑ C0WflY-AQNCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA Y,265 - -2agr TYPE F BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N RESERVATION or M of TANIC4 I G455TATION ❑ 3 FARM ❑ 5OTHER TRUSTLANDS ❑ ATTHIME EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE Al WITH AREA CODE M/Vf1R-f, A45- O -2-668 Orr A - igl- 6 NIGHTS: NAME(LAS)FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME J CARE OF ADDRESS INFORMATION C MAILINGor STREET ADDRESS ✓Box to iriEicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,ndicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVi4MESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ IL ❑ 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 S SIGNATURE) pgTE LOCAL AGENCY USE ONLY COUNTY a JURISDICTION N AGENCY R FACILITY ID a M of TANKS at SITE do Ooo CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE a WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMR EXPIRATION DATE LCHECK# ODE CENSUSTRACTO SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DATE p E YES NO Fl/// /PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTa BY: a7laa 1 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. / \V\111 FORM A(3-2-88) [V/% \ `,. DATA PROCESSING COPY "we