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STATE OF CALIFORN6wo' WATER RESOURCES CONTRb,.,JOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m hiT COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E_j6 TEMPORARY SITE CLOSURE W O� I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAM Q e h r(.rW FG�'i'►'l S CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓&abilorNN DPNRNBISW D STATE-AGM 137 2 f /V Cuwr °o `er"'N" o wj o RAW-AGB lA CITY NAME "V , uTATCA ZIPlQJ)E �O SIT HONE M, mRlcf (0 ARE'f&CODo TYPE OF BUSINESS: E]p BUTOR ❑ /PROCESSOR ✓Box it INDIAN EPA ID N ' F of TAMC$ ERVATION F-11 GAS STATION G FANM ❑5 OTHER RTRUSTT LA DS ur ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) ��YA.PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE - et WaIX go9J 36y-402- NIGHTS: RAME(LAST.FI ) PHONE N WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME ^ / ^ CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS lJ I /IL ✓Box w ino.mte 1:3PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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 w STREET ADDRESS ✓Boxtainoicete D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D 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: L ❑ N. [:] IS.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION N AGENCY N FACILITY IDN M of TANKS at SITE " r, lq 10qP n © c) r CURRENT LOCAL AOENCYFACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUIMER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION COOP CEtMO TRACT N SUPERVISOR-DISTRICT CODE BUEIMEBB PIAN FILED DA IRED (may( e23- P_9- YES � NO � CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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(3-2-88) mow. �