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'A'4N # 'V3- y0 71.�-9 STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': " "- UNDERGROUND STORAGE TANK PROGRAM _ wa SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '° G COMPLETE THIS FORM FOR EACH FACILITY/SITE s^" MARK ONLY ❑ 1 NEW PIRMIT ❑ 3 RENEWALPERMIT ANGE OF INFORMATION ❑7 PERMA QQO E }'4. ONE ITEM ❑2 INTERIM PERMIT ❑4 ENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS'- (MUST BE COMPLETED) Fy FACILITY/SITE NAMECARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓gNpYATyp ❑ PARTMRSHP ❑ STATE ASML 7 — 1:1COYORTION 11LOULASENCY ❑ fE(XRALAUNCY _ 11A1 A D ❑ C"TY-AGINCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑/PROCESSOR ✓Bax if INDIAN EPA ID N ❑ ❑ ❑ TRUSTYLANDSATION m ❑ AT THIS SITE I GAS STATION 3 FARM 5 2R EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NM E(LAST,FIRSTI PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING m STREET ADDRESS(, / ✓Box to micate ❑ PARTNERSHIP ❑ STATE-AGENCY � '37 �S // 6y �(� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Q INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE P NEM WITH AREA CODE G� 3 !00 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME n CARE OF ADDRESS INFORMATION T � MAILING a STREET ADDRESS ✓Box to imicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. ❑ it. 111.❑ 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 If AGENCY# FACILITY IDN �j Kot TANKS at SITE CURRENT LOCAL AGENCY FA ITY ID N APPROVED BY NAME PHONE N WITH AREA CODE -.2-3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATtnN CnDL CEHms TRACY SUPERVISOR-DISTRkgyCODE BUSINESS PLAN FILED DATE LED YES El NOE] I?I CHECK# PERMITAMOUNT SURCHARGE AMOUNT 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-BS)