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r STATE OF CALIFORNIA- WATER RESOURCES CONTROMOARD y FORM `A': UNDERGROUND STORAGE TANK PROGRAM �e SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA OSEO SITE F'r ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION l� N 1 N ADDRESS NEAREST CROSS STREET %/ft W w IP ❑ STAR6 ENCY �Q(11�15Gd/G/� ❑ NDooloN Loc ry El Rcoc ❑ IIu11 CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE AA 't4'� CA 9y TYPE OF BUSINESS: DISTRIBUTOR ❑ NPROCESSOR -/Box it INDIAN EPA ID p If TANKY ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION ur ❑ AT THIS SITE �— EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST.FSR PHONE N WITH AREA CODE a 11114-11 NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME ^ / / CARE OF ADDRESS INFORMATION MAILING or STREETRESS w /� ✓Box to indicate 1-1PARTNERSHIP ❑ STATE-AGENCY ✓r G tMV�r/ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME STATE ZIP CODE� PHONE p,WITH AREA CODE — III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CAPE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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: 1. ❑ H. wl 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 M JURISDICTION If AGENCY* FACILITY ID Al N of TANKS at SITE ml 16 01/-/ 10 1 10 0101 CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCH N DE CENSUSTRACTII SUPERVISOR-DISTRICT CODE SUSINESSPLAN FILED DATE FILED Zb VES ❑ NO ❑ 6 — CHECKa PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY4 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) DATA PROCESSING COPY �.1Ps