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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z C COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE rya 5 O I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 3 4 Cl FAC LITY/SITE NAME l I^' CARE OF ADDRESS INFORMATION L[.L ADDRESS ClNEAREST CROSS STREET ✓ gi�@ule ❑ FARINERW ❑ STATE AGENCY Si Dh (%1RPDmnm ❑ LDGALAGENCY ❑ ROEMI.AGENLY INDMDUN- ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE D G 4e�_ CA (,-to fr '��7 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4PROCESSOR ✓Box it INDIAN EPA ID x N of TANK'I ESERVATION ❑ I GAS STATION ❑ 3 FARM W'S OT R TRUSTT LANDS or ❑ l�W —0— AT TNI$SITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS.�NAME{LA IST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE f�j j.^,-.J.J. ?-1 Ifa NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE S a,-Y� II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION L PP-4-67 pa MAIUNG jREET ADDRESS ✓ ox to indicate [I PARTNERSHIP ❑ STATE-AGENCY 5Cl CORPORATION ClLOCAL-AGENCY ClFEDERAL-AGENCY INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE N v 11 ooaa, III. TANK OWNER IN RMATION & ADDRESS - (MUST BECOMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS '(71 I/ ✓Box to inoicaly ❑ PARTNERSHIP ❑ STATE-AGENCY CI CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE O,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. if. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N _L) ' J ,}' N of TANKS at SITE 601 CURRENT LOCAL AGENCY FACILITY ID P APPROVED BY NAME PHONE P WITH AREA CODE r PERMIT MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION(On CENSUS TRACT P SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OATS F LED , I YES [:] NO a .L ' CHECK N PERMIT AMOUNT SURCHARD ANIOUNt FEE CODE RECEIPT Y BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) I/I n DATA PROCESSING COPY /mak-' �