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STATE OF CALVFORN � { WATER RESOURCES CONTRZ7CBOARD °`��: '�• FORM `A': SIT UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, �^ Y/SITE, INFORMATION and/or PERMIT APPLICATION Z c COMPLETE THIS FORM FOR EACH FACILITY/SITE `+r„ora 1 MARK ONE ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANE LY CLOSED SITE I_& 2 INTERIM PERMIT El 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) A FACILITY/SITE NAME P � CARE OF ADDRESS INFORMATION L 4 i O ADDRESS {' NEARE/S�T CROSS STREET ✓9mlogoole ��❑❑ �P�G��AXR�1BISHp ❑ STATEAGDO w,- S,�x •, u, r G ❑ NOMGIIMNTION LJ 1V-AGQILY ❑ FEGEMLAGBICY -< CITY NAMEAGENCY O ; AGENCY STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA 5 A Y TYPE OF BUSINESS: 2DISTRIBUTOfl 4PR SSOfl ✓Boa if INDIAN EPA IDN I GAS STATION 3 FARM OTHER RESERVATION or ❑ - - N of TANK'N TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) - EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE �1'i NIGHTS: NAME(I-AST FIRST) PH NE#WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE S 0 _ v Cx_ I II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION I MAILING or SIRE GORESS / I j2 ✓Box to intlicale ❑ P NERSHIP C3STATE-AGENCY„L� 1 rM^� ❑ CORPORATION OCAL-AGENCY ❑ FEDERAL-AGENCY -0` ❑ INDIVIDUAL Cl COUNTY-AGENCY GHY NAMESTATE ZIP PHONE N.WITH AREA CODE Lodi C/1 CODED AO 9 3 —vrG� III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME .0” 411 671PAIhy CARE OF ADDRESS INFORMATION S a S no MAILING or STREET ADDRESS v ✓Box to intlieale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY R FACILITY ID R If of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDM APPROVE BY IN J PHONE I WITH AREA CODE PERMIT NUMBER lY^) PERMIT APPROVAL DATE (/T'A6 CC.. I y✓PE('RMI))ITT 1EEXPIRATION DATE LOCATION CODE I CENSUS TRACT N If - SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED PEIRMZ, � / YES NO� PYTL- ( 1 Lf Z.��s'� ' .��s'� 'CHECKN PERMIT AMOUNT SURCHARGE AN NT 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. FORM A(3-2-88) Jl -i.�. DATA PROCESSING COPY