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STATE OF CALIFORNIA WATER RESOURCES CONTR04PBOARD "e FORM `A': UNDERGROUND STORAGE TANK PROGRAM ^ SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r COMPLETE THIS FORM FOR EACH FACILITY/SITE °+A,FOR MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I �) W I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION O Je t.CLC� I run S^I-c,_-h'cm ADDRESS NEAREST CROSS STREET ✓Bu W,Ml8IB 0 PARTNERSHIP 0 STATE AGENCY aJ Lov-e Lo" 0 COR DON 0 LOCALAGENCY 0 FEDEBALAGBICY CITY NAME ❑ INDMUUAL 0 COUNN AGENCY STATE ZIP CODE SITE PHONE k,WITH AREA CODE CA TYPE OF BUSINESS: p DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID k I GASSTATION � 3 FARM 5 OTHER TRUSESETYLANDS ATION ATION or ❑ _ AT THISIf of SITE AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box lointlicate ❑ PARTNERSHIP 0 STATEAGENCY0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 11 INDIVIDUAL 1:1 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓8ox to irdlc.te 0 PARTNERSHIP 11 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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. El if. 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 COUNTYTV JURISDICTION Al AGENCY N FACILITY ID N N of TANKS at SITE 3 9 -t t a- o 0 o cp CURRENT LOCAL AGENCY FACILITY IDN LOVEL-o APPROVED BY NAME PHONE N WITH AREA CODE l PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED ` �J-� X, YES ❑ NO O� /+„1 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY. l.t�+ 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. /FO/qM A(3-2-88) 1/ DATA PROCESSING COPY