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STATE OF CALIFORN�,1 WATER RESOURCES CONTR6"OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM =" o SITE -OFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ NTLY CLOSED SITE ONE IT ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE1221 Z I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) I FACILITY/SITE NAM� CARE DDRESS INFORMATION ;ftM ADDR SQ N R TCROSS STREET ✓Bmbolma 0 PARTNERSHIP 0 STATE AGENCY N SS ❑ 00WORAT10N 0 LOGAIAGENLY AAL NC 0 INOIVIDIIAL 0 COUNTY co CITY N ME STATE ZIP C DE SITE P j NE N,WITH AREA CODE (� CA TYPE OF BUSINESS: 2DISTRIBUTOR /PRCCESSOIi ✓Box i'INDIAN EPA Ipa #oI TANK'# [:] 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST HANDS dr ❑ AT 7NIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMEI'GE111 CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.PIRST) PHONE N WITH AREA CODE DAYS: NAN LAST,FIRST) P N NWITHAREACODE NIGHTS: Ng (LAST,FIRST) PHO E N WITH AREA CODE NIGHTS ME(LAST,FIRST) P N N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NA N 'k/J .J CARE O A EBS INFORMATION MAILING ar STRE ADDRESS _ ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCYER -AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CJ7XNAME STATE ZIP ODE PHONE WITH kREA CODE III. TANK OWNER INFORMATION &;.A'ADI�D/REES,S - (MUST BE COMPLETED) l 14/A��✓ P� , v CAR CAlDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY EDERAL E CV ❑ INDIVIDUAL 0 COUNTY-AGENCY ITY NAyf STATEZIP JS HONE N, ITH AREA CODE Cr IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE 1 yF = = 1 .01 D I A (- 17-1051 16 1 a 10 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LL#'lCENSUSTRACT# SUPE V R•DISTRICT CODE BUSINESS PLAN FILED DATE ILEpVES ❑ NO ❑ O , PERMIT AMOUNTSURdHkRGk AMOUNT FEE CODE RECEIPTN Y: 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. FORMA(3-2-88) DATA PROCESSING COPY �.