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STATE OF CALIFORNIA WATER RESOURCES CONTROL HARD FORM 'A': "T UNDERGROUND STORAGE TANK PROGRAM = " o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PEM CLOSED SITE ¢—L ONE ITEM ❑ 2 INTERIM PERMIT El4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C" FACILITY/SITE NAME /wT�`W� �_ CAREOFAO�SS INFORMATION 0 ADDRESSS / NEARESTTCCRQS§S�TREEj ✓Em toiMirale ❑ PARTNERSHIP ❑ 81ATE AGENCY A—l� �L"KK[r ❑ COAPGII4ilON ❑ LOCAL AGENCv rATE A- ENGY ❑ INDMDUAL ❑ COUNIY-AGENCY CITY NAME STATE ZI ODE `�V SITE PHO E 4,WITH AREA CODE Q t CA SS Zo 6 �` 3 71 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 LESSOR '/BOX it INDIAN EPA ID a RESE❑ 1 GAS STATION F-13 FARM 5 OTHER TRUSTYLANDS Or ❑ �V AT THIS SITE 0 EMERGENCY CONTACT PERSON(PRIMARY) EMERG NCY CONTACT PERSON(SECONDARY) DAYS' NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N ITH AREA CODE 368 S37 S J9 A NIGHTS: NAME(LAST. ST) P NE 4 WITH AREA CODE NIGHTS'. NAME(LAST FIRST) PHON k ITH AREA CODE S A SA� S S II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME � r✓CARE OF rtDRESS INFORMATION MAIA' G or STREET ADDR SS �./ ✓Box t.,ndicate 13 PARTNERSHIP 13STATE-AGENCY 7 -C] Cl CORPORATION ❑ LOCAL-AGENCYF DER -A ENCY ❑ INDIVIDUAL 13COUNTY-AGENCY CITY NAME // STATE ZIP CODE PHONE 1,WITH AREA CODE D etc " Z YLJ III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME A CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toinrlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME 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. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYAI JURISDICTION R AGENCY N FACILITY ID M R of TANKS at SITE O V V CURRENT LOCAL AGENCY FACILITY IDN APPROVED BYNA PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCIMECK# CODE CE-N�fSUS TRACT k'\ SUPERVISOR-OISTRICT CODE BUSINESS PLAN FILED DATE FILED _ �� [- V ` YES NO PERMIT AMOUNT SURCHARGE AWOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONS UNLESS THIS 1 APPLICATION(S), S S A CHANGE OF SITE INFORMATION ONL' FORMA(3-2-SB) DATA PROCESSING COPY