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STATE OF CALIFORNIA-` WATER RESOURCES CONTROLVOARD 56F� '�f e FORM 'A': _ q �o Z UNDERGROUND STORAGE TANK PROGRAM SITE-FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -' 10 J. COMPLETE THIS FORM FOR EACH FACILITY/SITE ""-" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Lef 7 PERM SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACIA NAME e CARE F DDRE NFORMATIII ADDRESS NEA {51/Zr�CRAOSSS�TRE/E/T ✓fro,x v Cl PNMEMHP ❑ STATE-AGENCY O 1PIA7LGN E3 louA _GENCY Cl ®E0.k-ADEN INGMGUAL 0 LOCALAADO CITY NAM[, `_ STATEA Irp T N HARE QO/ TYPE Of BUSINESS: ❑ 2 DISTRIBUTOR ❑ d P CEWR -/Box if INDIAN EPA ID a ✓\ a of TANK'L RESERVATION orEl / A AT THIS SITE V O ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ,`� ✓e EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAS .FIRSTI -PHONE#WITH AREA CODE DAYS: NA E(IAST,FIRST) PHARE P X41TH AREA CODE L✓ 7J 064 l0 fi NIGHTS: NAME(LAST IRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE ,5s A 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 51A MAILING or SIREADDRESS ✓Box to mclicata 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY A ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE*.WITH AREA CODE 5 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or S ADDRESS ✓Box to intlicale 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 2.� 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME A STATE ZIP CODE PHONE*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. 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION* AGENCY R FACILITY ID k R of TANKS at SITE = D 16 1 q! ! ID O 16 CURRENJ LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE u , m ef/ 6 PER UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPER n T111CT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO Mr— U `uI CHE a PERMirAmouNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: . . II THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FDR*A(3-2-83) 1� DATA PROCESSING COPY 1..."