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5��Wvy x'tf STATE OF CALIFORNIA► WATER RESOURCES CONTROL ..JARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE 2ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m C4LifO RN,P COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-1 I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION El PERMANENTLY CLOSED SITE ONE ITEM El2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME // / CARE OF ADDRESS INFORMATION /`// ,�\f/•�'�ffn/� NEAREST CROSS STREET ✓S WMiuN ❑ PARTNERS IP ❑ STATE-AGENCY -ADDRESS �� ` fJ_� �0�� ❑ p'NN7R1ilON ❑ LOGLAGENLY ❑ /EGEAl1AGDICI' `/`'/F/��j^J/ 4elf 09 ❑ INDNIWAL ❑ OIUNtt-AGENC/ CITY NAME .� STATE ZIP CODE / SITE PHONE M.WITH AREA CODE CA 6 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR E] A PROCESSOR Box if INDIAN EPA ID p N 01 TANK's ❑ I GAS STATION F-] 3 FARM E: RESERVATION or AT THIS SITE 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M 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 w STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 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. ❑ it. ❑ 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 R JURISDICTION R AGENCY R FACILITY ID N N of TANKS at SITE d0blob ifl— CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE M AAA S PERMIT NUMBER PERMIT APPROVAL DATE PERMR EXPIRATION DATE LOCATION CODE CENSUS TRACT0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO [:] DATE FILED 3/ 2 (J d OV CHECK• PERYR AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY /f0 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. FOORMA(33--12--98)