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STATE OF CALIFORNm, �' WATER RESOURCESCONTR(JL..DARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE M FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° COMPLETE THIS FORM FOR EACH FACILITY/SITE FZRKONLY F-] I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ TLY CLOSEDSITE ONE ITEM ❑2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &A,DJDDRREES'S — (MUST BE COMPLETED) 1 FAPI /SITE NAME -`w CARE OF fjDDRESS INFORMATION ADDRESS e /.. NEAREST CROSS STREET ✓Bm loiMiuN ❑ PARTNERSHIP ❑ STATEAGEVCi ❑ CDRPMTICN ❑ LOGLL-AGENCY ❑ FEDEAPlq ENLY E INDIVIDUAL ❑ COUMYAGENC/ CI CITY NAME STATE ZIP CO S TE PHIE N,WITH AREA CODE CA q S�Z'z t-1-3-54_y TYPE OF BUSINESS: ✓ EPA ID p ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR Box if o RESERVATION or k o1 TANKb Iy1/GAS STATION 3 FARM 5 OTHER ,AI ,, {„� AT THIS SITE [�/ ❑ ❑ TRUST LANDS ❑ 'V /"'A EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PH E N WITH AREA CODE DAYS. NAME HAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE TH AREA CODE NIGHTS: NA E(LAST,FIRST) PHON N WITH AREA CODE S S" Ef 1A VA II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE SOF/AD RESS INFORMATION til A MAILINGgLSTRUT ADDRESS ✓Sox to inchoate 1❑ PARTNERSHIP ❑ STATE-AGENCY �Y ❑ CORPORATION ElLOCAL-AGENCY ❑ EDERA AGENCY U & �iAN/�� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE CA qr z yv 7179- 3 V III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME O CARE OF AOD E$lb INFORMATION 14 MAILING DRESSf� ✓Bax to mftate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY - GENCY '.try e,,...�tj/�� , ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME ('�?�l1'�""�-_ STATE Z . "V, RHO n rAITH AREA CODE Qm ld/� 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. ❑ IN.vr THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLERGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY 'fJD COUT�II�NTTY M JURISDICTION R AGENCYIN FACILITY ID n N of TANKS at SITE `—�' E= V © D CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY.NAME PHONES WITH"IA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT ON CODE CENSUS TRACT M SUPERVISO •DISTRICT CODE BUSINESS PLAN FILED DA FI E OYES NO CHEC N PERMIT AMOUNT SURCHAR73E AMOUNT FEE CODE RECEIPTS BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONE FORM A(3-2-SS) '., % — DATA PROCESSING COPY .moi