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t STATE OF CALIFORNI9 WATER RESOURCES CONTRAOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM 6. " SITE ,`_rFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 HANGS OF INFORMATION 7 PERMA TLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �r I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I C FACILITY/SITE NA E CARE OF �DRESS INFORMATION ADD S/� ,,11 \�TQ/�l•`a• •\Z(��N,•v NEAREST CROSS STREET B.to"dale ElPARTNERSHIP ❑ STATE N V�V S• ❑ CORPORATION ❑ LOCALAGENCY EDENL ENCY b 1 ❑ INDIVIDUAL ❑ courvn-Ac Nw00 CITVyIAME STATE ZIP OD ITE PH NE#,WITH AREA CODE I a TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i1 INDIAN EPA lD p ❑ I GAS STATION ❑ 3 FARM ©'POTHER TRUSTRESEY ANDS N ❑ #of TANK's AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMER ENCY CONTACT PERSON(SECONDARY) DA NAME(LAST.FIRSTJ PHON7 WITH AREA CODE DAYS N ME(I ART,FIRST) PHONE p WIT AREA CODE (9I/I� A NIGH NAME(LAS .FIRST) PHOtAWITH AREA CODE NIGH VAME(LAST,FIRST) PHONE#WTH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME - CARE OFdftDPDRESS INFORMATION MARLIN o S/TR ET ADDRESS ✓ oxtoindicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY F DE- R/yL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY (/N:4 CITY NAME STA ZIP CODE PHONE p, PTH AREA CODE S A III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME r l/"V V w CARE OF ADDRESS INFORMATION MAILING T TADDRESS ✓box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCYFEDER L-AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAM STATEI, ZIP CODE PH E r7VTH 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. ❑ If.❑ 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 N FACILITY ID# #of TANKS at SITE 1010 1 lul CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME.. PHONE p WITH AREA CODE Tg 376 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L DE CENSUS TRAT# SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED D FILED elf 2_74`6 `51 YES 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