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n -�„�AIF>•yil'6i1�•yy...rr ..-�x'i r4VI"�'$Te`•i4.`�6YT1P�P.l�l' �.;; ryS�T�'�rcTf'p•_ mu+....gYla. •,r' .�H.+ .T �. STATE OF CALIFORNIX WATER RESOURCES CONTRO BL OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u �" SITE = FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION = to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMA3TTL CLOSED SITE N ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 66 CTI 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) O FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Aia 1�� ADDRESS - II ' NEAREST CROSS STREET ✓Bmtrindii Cl PARTNERSHIP [I STATEAG'NCY S 5 Ni A IG f(3( 11DOOli ❑ RF➢A -AGC MI]ieWMac CITY NAMEff l • STATCA ZIP CODE SITE PHONE k,WITH AREA CODE TYPE of BUSINESS: F-12 DISIRIBUTOR ❑ 4 PROCESSOR I/Box if INDIAN EPA ID If 5 RESEF] I GAS STATION E]3 FARM ❑ 5 OTHER TRUSTYLANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS'. NAME(IAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(IASL FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION e MAILING or STREET ADDRESS Be.✓ to indicate D PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME 17 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate D PARTNERSHIP D STATE-AGENCY 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ 11. ❑ ILL ❑ 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 N JURISDICTION N AGENCY N FACILITY ID R II of TANKS at SITE 3 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE If WITH AREA CODE CJS PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT pN CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / '1 _Z 6 YES NO El '2Q C• CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST ISI OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI FSS THIS IS A CHANGE OF SITE INFORMATION ONLY. j FORM A(3-2-88) DATA PROCESSING COPY ""i