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STATE OF CALIFORNIA WATER RESOURCES CONTRO OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM =" SITE lam/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•oa�" MARK ONLYI NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAN TL LOSjD SITE N ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / 0) W I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N FACILI SITE ME CAPE OF DRESS INFORMATION ADDRESS N��]EST CROSS,SBRF�; 1V-Erxb MATO ❑ LOCAL ASEN ❑ SiAiE-AGENCY _xf // `\'��/' ❑ FPRPOAAiIGN ❑ LOCAL AGENCI ❑ LEGEPAL AGENp III111 2 11"ItDUAL ❑ COUNTY AGENCY CITY NAME / STATE ZIP OCEITE PHON p,WITH AREA CODE CA SZYO p 3 TYPE OF.BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESMR ✓Bax it INDIAN E(PA IDD a IF of 1 GASSTATION 1:13 FARM ❑ 5 OTHER TRUSTVLANDS U ❑ /L/ w AT THAS SITE 0 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) WE AME(SART,FIRST) PHONE k WITH AREA CODE DAYS-)AME(LAST,FIRST) PHONE 11TH AREA CODE r �0 3?3•�33y �/�4 A NIGHT$ NAVE( ST, IRST) PHONE M WITH AREA CODE NIGHT NAME(LAST,FIRST) PHON WITH AREA CODE aA531 Q A II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NA _ECARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.to od,d to ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NANE,/LA CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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. 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 R JURISDICTION IF AGENCY N FACILITY ID N Al of TANKS at SITE G a1 If FTZ b a 1 o CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE L/ Z z ?i1 PERMIT NUMBER PERMITAVGRO AL DATE PE MIT EXIIIIIATICINDATE LOCIATION�CODE CENSUS MCT� UPERVISOR-DISTRICT CODE BUSINESS P S N FILED NO SE FI}Eq, CHECK N L/ PERMIT AMOUNT SURCHARGGEE A•MMOOUU`NNT FEE CODE RECEIPTN y(LjV'BY:: THIS FORM MUST BE ACCOMPANIED BY AT LEAST 0)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 FORMA(3-2-5&) DATA PROCESSING COPY lw