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STATE OF CALIFORNIA'' WATER RESOURCES CONTROLARD YP �9A �e FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7,W&WA4iINTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O/ I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 10 FACILITY/ ITENAME /) CAREO A DRESS INFORMATION ADDflESS / 1 REST CROSS STREETTT��''' to intl¢ale ❑ PARTNERSHIP ❑ S' AGENCY N NA LIUN ❑ COCAL AGENCY EBA CY co INDIVIDUAL ❑ COONT'-AGENCY CITY NAME STATE ZIP CODE ITE PH E p,WITH A A CODE co SL LODI CA Z - sbo TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d P OCESSOfl -/Box if INDIAN EPA ID p ##f TANK'a RESERVATION or ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE G 7� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAYE(LAST,FIRST) PHONE N ✓ T AREA CODE JA S S NI TS NAME(_RST,FIR PHONE N WITH AREA CODE NIGHTS AME(LAST,FIRST) PHONE H AREA CODE kt/vu.Gvu 36 -or6r 1 A S II. PROPERTY O NER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ,,� CARE OF ADDRESS INFORMATION a) V �/� MAILIN or STREET ADDRESS ✓80x to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY IL V� ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE P ONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) ry CV"'RPORATION ESS INFORMATION Aii MAI orS TADDRESS to odicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ LOCALAGENCYCl FEDERAL-AGENCY Pa-D, ❑ INDIVIDUAL EICOUNTY-AGENCY CITY AME STATE ZIP CODE _HHONE N. ITH AREA CODE Low' CA cZ. o Co 334-6 00 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE YE = = lob 11 173= 10 10 CURRENT LOCAL AGENCY FACILITY ID# APPR VED Y NAME PHONE N WITH AREA CODE PERMIT N`NUUMBER PEP IT PR V DATE 9 ^/ PERMIT EXPIRATION DATE 7 LOCATION CODE CENSUSTRACT# SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED DAT FILE p z� 0 YES NO CHECK N PERMR AMOUNT SURCHARGE MOUNT FEE CODE RECEIPT# B 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) DATA PROCESSING COPY +r