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yF 9 IwYE i�T T[ e,igTsoP•.a��..v-.`..�,z.n...�*n,F. .o_ �;.:. STATE OF CALIFORNI? WATER RESOURCES CONTROL OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM =" ' a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACT ITY/SITE 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 Lim 10 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME 40FTADS INFORMATIONlLADDRESS STRIEEET ✓B.tomd.te ❑ PARTNERSHIP ❑ STATEAGENCY// �, S#'"– CORP"T N ❑ LOCM AGENCY ❑ FEDEAALAGEND X70 UV 1 1AL ❑ CO3NTYAGENCYall CITY NAME ZIP CODE / SITE PHONE#,WITH AREA CODE as 2.0 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'# ❑ 1 GAS STATION ❑ 3 FARM OTRER TRUST LANDS RESERVATION o ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST IRST) PHONE#WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE �IITHTS NAME(LAST, IRST) PHONE 9 WITH AREA CODE NIGHTS. NAME(LAST FI T) PHONE At WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION MAILING o1 STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY [:] C DIVIDUALIFEDERAL-AGENCY 22, ON [I COUNTY AGENCY CITY NAME STATE ZIP CODE ONE#,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESSINFORMATION MAILING or STREET ADDRESS I/Box Ito—odllr;WeiCiL/LSE/ PARTNERSHIP ElSTATE-AGENCY ❑ C RATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY el 0 4DIVIOUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE�t 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# *SURCHARGEAMOUNT PROVED BSYTNAME PHONE#WITH AREA CODE e _2s__K' PERMIT NUMB PERMIT PERMIT EXPIRATION TE LOCATION CODE CENSUS TRACT# E BUSINESS PLAN FILED DATE FILE �j YES NO �/o—� CHECK# PERMIT AMOUNT FEE CODE RECEIPT# BV: 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