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STATE OF CALIFORNM' WATER RESOURCESCONTRIOLBOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM mo SITE E/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o r (_l COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEUILYCLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 19,67 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) -J FACILITYAVE � . . CARE OF RESS INFORMATION N/ � ADDRESS 11 PAREHIP ❑ STATE C Sol ( c 13 LauG ❑ OW.AaHa INDIVIDUAL 13 AUNTY AGENCY CITY NAMEf STATE ZIP CODE TE PHO #,WITH AREA CODE -, LoCA q Divi, 33S •/ Z¢z TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR I -/Box it INDIAN EPA.IDI# #of TANK's ESEGASSTATION [:]3 FARM 1:15 OTHER TRUSTYLANDS ATION or ❑ /� AT THIS SITE 6 } EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) P ONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHO N WITH AREA CODE ?07 8 S A NIGHTS: NAME(LAST,F ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONED WITH AREA CODE 5 A .l - 7 S S/� II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMEfD✓ [°o CARE OF DRESS INFORMATION l bbd , N ,n MAILING of STREET ADDRESS ✓�xto inflate ❑ PARTNERSHIP 0 STATE-AGENCY S // CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY J ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE !mss C/4b Do yap- srS III. TANK OWNER I ORMATION &ADDRESS — (MUST BE COMPLETED) NAME CA OF ADDRESS INFORMATION MAILING y,STREET" ESS 6 ✓Boxw odicale IllPARTNERSHIP 0 STATE-AGENCY ,� 0 0 y s ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY N99ME��" ee -�� ST ZIP DE PHONE#,WITH AREA CODE G(/�r�v S Da Z/ 7 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID If If of TANKS at SITE 0 10 3 1 16 10 10 13 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE f}RC 6M PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECKO E CENSUS TRACT# SUPERVIS R-DISTRICT CODE BUSINESS PUN FILED DATE FILED ' J7, QYES ❑ NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. FORMA(3-2-88) �'- DATA PROCESSING COPY