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STATE OF CALIFORNW' WATER RESOURCES CONTROL-WOARD :sf `""''l'`` r .: .'�m FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o i SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FOR EACH FACILITY/SITE �""�""�' MARK ONLY ❑ 1 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 Z 161 1.FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE O"DDRESS INFORMATION ADDRESS NEA ST CROSS STREET ✓ Io inrcae 0 PMNEMHIP 0 STATE AGENCY 00 00 !/J.N./I LITCORPORATION 0 LOCPLAGENC! 0 FMEAALAGENCY Aldyv ❑ INDIVINAL 0 WUNTY AGENCY CITY NAME C STATE ZIP ODE S PHONE M,WITH AREA CODE 5fi /✓ CA q Z D b -Z7-O ' TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑^4C P,,R�OCESSOR ✓Box if INDIAN EPA ID a R BI TANK'e /) ❑ I GAS STATION ❑3 FARM L�"�"""_ RESERVATION RUST LANDS or ❑ �'� AT THIS SITE V EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIflST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE k WITH AR A CODE �Db �j\ D NIGHTS: NAME(LAST, RST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAM G �� CARE OF ADDRESS INFORMATION V-1/ L SMY N✓1 MAILING or STREET ADDRESS xtc ind ate 0 PARTNERSHIP 0 STATE-AGENCY 'O. / CORPORATION ULOCAL-AGENCY U FEDERAL-AGENCY Z 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PH ONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME ' CARE OF ADD EAS.S INFORMATION (`�7 MAILIN SIRE ADDRESS ointlicale 0 PARTNERSHIP 0 STATE-AGENCY ET CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY O c.- 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME / STAT ZIP CODE ONE N,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 R JURISDICTION R AGENCY E FACILITY IDR R of TANKS at SITE I oUd6 CURRENT LOCAL AGENCY FACILITY ID M APPROV D Y NAME PHONE A WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRAC]M_ SUPERVI�ISTRICT CODE BUSINESS PLAN❑FILED ❑ DATE'ILED�� 3 SO//�, YES NO g CHECK# 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. FORM A(3-2-83) - �E DATA PROCESSING COPY ��