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/9E/^•iu�irt�'�f STATE OF CALIFORNIA • WATER RESOURCES CONTROL &RD r FORM `A': �m Z UNDERGROUND STORAGE TANK PROGRAM SITE !o FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r� C"I,FOPi`P COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PER CLOSED SITE F'J ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Q� I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACIeSS/ ITE E � / CARE OF ADDRESS INFORMATION L.�""" — NEAR TC SS TREET ✓BOFIO inOim ❑ PARTNERSHIP ❑ STATE AGENCY ADD ❑ CORPGR4ilON ❑ LOCAL AGENCY EOERAL FNCY Z, � NOIVIWAL ❑ fAl1N1YAGENCI�( C ,% STATE ``A Z� 13� ITEP ONE k.WI I HVREA CODE CITY NAMy/n TYPE OFL/BUSUi'NESS 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box d INDIAN EPA ID 'All M of TANK'e r, ��/ RESERVATION or AT THIS SITE J! ❑ 1 GAS STATION ❑3 FARM UQ 'OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) PHONE N WITH AREA CODE DAYS' N ME(LAST.FIRST) .A PHONE N WITH AREA CODE DAY AME LAS FI ST) � �l 01�0 P ONE Al WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS. ME( .FIRST Z 7 ] i-1 ( A L� - ') J W II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME S CARE OFAVRESS INFORMATION MAI or ST ET AD RESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY YJA� I y CORPORATION ❑ LOCAL-AGENCY ❑ FEDER L-AGENCY /r/ K S ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE#, ITH AREA CODE CITY NAME UA 9C-"/ 5LA III. TANK OWNER INFORMATION &ADDRESS— 'MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME51 A ✓Box CORPORATION indicate ❑ PARTNERSHIP ClSTATE-AGENCY MAILING or STREET ADDRESS NIV DUALO COUNTY-AGENCY [IFEDERAL-AGENCY El STATE ZIP CODE PHONE A,WITH AREA CODE CIN NAME 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 DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTYII JURISDICTION R AGENCY k FACILITY ID N M of TANKS at SITE ® D p l U O O APPROVED BY N E PHONE N WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID k �h L02.- PERMIT APPROVAL DAT PERMIT XPIRATION DATE PERMIT NUMBER LOCATION CODE CENSUS TRACT N S PERVI -DISTRICT CODE BUSINESS PLAN FILED DATE LED YES NO A RECEIPTM BY CHECKIf PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE \ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), USS THIS IS A CHANGE OF SITE INFORMATION ONLY. \v\\JSFORM A(3-2-88) j DATA PROCESSING COPY r