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yepl O.F rM1f STATE OF CALIFORNIA. ••-WATERRESOURCESCONTROL4VOP. d a \; FORM `A': UNDERGROUND STORAGE TANK PROGRAM � �a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION „o :P COMPLETE THIS FORM FOR EACH FACILITY/SITE fflMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE ! Z 10 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �r N ADDRESS INEAR EST CROSS STREET ✓Bow to irdirais ❑ PWNERSHIP ❑ STATE-AG9000 f� ❑ CO RATION ❑ LOCAL ❑ ROBOLAGENCY ^, II r a NIWAL ❑ C`Uii KAGEKCI „K CITY NAME �I G • ATCA 21P C0��o TE 1; ,WITH AREA COD�� S 7 �` C 1/C — TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a If of TANK's f L SO7HEP RESERVATION OT /) j� ATTHISSITE 7 GAS STATION ❑3 FARM ❑ TRUST LANDS ❑ T v EMERGENCY CONTACT PERSON(PRIMARY) - EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE G ' rl 4 &3- NIGHTS' NAME(LAST.FIRS PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONENWITH AREA CODE Sa Yr e II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION h r Gor STREET AD SS ✓Box to indicate El PARTNERSHIP ❑ ATE AGENCY MAIL1N ❑ C RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE/q ZIP CODE PHONE N,WITH AREA CODE -�5 Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING ar STREET ADDRESS ^ u ✓Box to indicate ❑ PARTNERSHIP El STATE-AGENCY ❑ CORPORATION ❑ 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: L ❑ 11. ❑ 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 COUNTY41 JURISDICTION R AGENCY R FACILITY ID N If of TANKS BI SITE 6 ® 7Z � 1600 ( CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE It WITH AREA CODE A PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ©, i 3A kD YES NO CHECK% PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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 -we