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STATE OF CALIFORNIA- WATER RESOURCES CONTROL-60ARD FORM'A': UNDERGROUND STORAGE TANK PROGRAM SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Li- COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7P T CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITYISITE NAME -? n^ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS \ a 0 CORPORATION D LOCAL -AGENCY Cl FEDERAL -AGENCY APPROVED BY NAME PHONE F WITH AREA CODE ADDRESS CITY NAME STATE tdkab 0 PAATW&W D STATE AGDO ON 0 11 L�Y±GiENCOCAL W01CY ❑FEDEAL, ' /_ If! 3 C -�- jAn. f22 ;NEAREESTCROSS✓Bmb I WAL CITY NAME /n Lu�'� DATE FILED I SITE PHONEp, WITH AREA CODE PERMIT AMOUNT !/'c FEE CODE RECEIPT 0 TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p N of TANICS F-11 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTI ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE M WITH AREA CODE DAYS: NAME (LAST. FIRST) PHONE p WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE p WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE Of ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,micate D PARTNERSHIP D STATE -AGENCY CURRENT LOCAL AGENr FACILITY 10 p F / 0 CORPORATION D LOCAL -AGENCY Cl FEDERAL -AGENCY APPROVED BY NAME PHONE F WITH AREA CODE D INDIVIDUAL 0 COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE p, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate 0 PARTNERSHIP 0 STATE -AGENCY CURRENT LOCAL AGENr FACILITY 10 p F / ❑ CORPORATION D LOCAL -AGENCY D FEDERAL -AGENCY APPROVED BY NAME PHONE F WITH AREA CODE D INDIVIDUAL 0 COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE p, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR OWN 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 8 SIGNATURE) DATE I nCAI ArFMCV uRF nMLV COUNTY M =1 JURISDICTION k AGENCY R FACILITY ID R S of TANKS N SITE Z_�0= I 1 1 16, CURRENT LOCAL AGENr FACILITY 10 p F / APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION C CENSUS TTIACTN SUPERVISOR -DISTRICT CODE BUSINESS P $N❑SLED ND ❑ DATE FILED I CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 0 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)