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STATE OF CALIFORNIA` WATER RESOURCES CONTROLVOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE C' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; Io COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F'J ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMITCc E] fi TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) by FACILITY E -, 7/� CARE 0 ; DE4S INFORMATION ADDRESS / /��,q ) NEAREST CROSS STREET ✓WFOMnO ❑ LOCAL AGENCY El STATE AGENCY 7C.�(CJ f/'�/J✓�V✓�'Vr� F1 IND L� El COUNTYAGENGY GSL-GENCY CITY NAME / STATCA ZIP CODE Z�/ SITE P ONE..PITH AREA C E TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p F of TANK'S GAS STATION 1:13 FARM ❑ 5 OTHER TRUSTESEYLANDS ATION or ❑ A AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) 06f. ryAME( ST,FIRST) HONE p WITH AREA CODE DAYS'. N ME(LAST,FIRST) PHON p WITH AREA CODE u �C o ( 3b 9-yV, Jdv HT NAME(LA ,FIRST) PHONE N WITH AREA CODE NIGH: NAME(LAST,FIRST) PHON N WITH AREA CODE II. PROPERTY 6WNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME J. Fw ✓ ✓ CARE 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 III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAM cc_� CARE OF ADDRESS INFORMATION MAILING oySTf}EEJ ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ TATE AGENCY CJ/✓/Ib ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMVA 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: I. jzj it. ❑ ILL❑ 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 N JURISDICTION N AGENCY S FACILITY ID N M of TANKS at SITE O 1 13 1 3 171 10 10 CURB LOCAL AGENCY FACILITY ID M APPROVED BY NAM PHONE N WITH AREA CODE S rTJ,nr✓'M/A ZS G /D ZD PERMIT NUMBER PERMITAPPR ALD r PERMIT %PIRATION DATE LOCATION CODE CENSUS TRACT N S PER OR-DISTRICT CODE BUSINESS PLAN FILED GATE FILED YES NO CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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. ��77 ORM A(3-2A8) `~ DATA PROCESSING COPY