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STATE OF CALIFORNIA" WATER RESOURCES CONTROL 9OARD A I FORM A: UNDERGROUND STORAGE TANK PROGRAM �a Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o l l o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a) 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION %.ems N ADDRESS NEAREST CROSS STREET ✓B WTIO ❑ PARTNERSHIP ❑ FSTATE EEERAGENCY 6 /�.e b J� RVIDUALON ❑ LOG4LAGENCY ❑ ➢FNAL AGENCY J ,A✓TAT/FBF„ �� INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME S 72e,4/ STATCA ZIP ODE SITE PHONE N,WITH AREA�E 2 O TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N JJ ''G,(/•N of TANNK'NRESER ^3/ 1 GAS STATION F-13 FARM ❑ S OTHER TTRUSTYATION LAND$or ❑ ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS y�yE(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME VA W/ /J o 16ex- CARE OF ADDRESS INFORMATION N /l/�C//P 1 MAILING or STREET ADDRESS , �./ ✓So Io Indicate 0 PARTNERSHIP ❑ STATE-AGENCY RIPORAT7- �l L7-0 /7 ✓� INDIVIDUALION El COUNT AGENC FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 21-3 III. TANK OWNER INFORMATION & ADD ESS- (MUST BE COMPLETED) NAME V f _ � CARE OF ADDRESS INFORMATION MAILING or STREET ADpQQpRRESS ✓$fix to indicate ❑ PARTNERSHIP Cl STATE-AGENCY (! O Q O /��/ L4CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY ' I Q p INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 37®Z-�70i✓ IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N k of TANKS at SITE v lo 1 1 a 0el CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY ME PHONE N WITH AREA CODE S1Z_ VE6o w PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCIE DE CENSUSTRACTN SUPERVISO -DISTRICT CODE BUSINESS PLAN FILED DATE FILED 23 IfO Zp YES NO PERMIT AMOUNT SURCN RGE AMOUNT FEE CODE RECEIPT N 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) DATA PROCESSING COPY