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STATE OF CALIFORNipr WATER RESOURCES CONTROMOARD S,,I.I Oi�jtie FORM 'A': UNDERGROUND STORAGE TANK PROGRAM t - " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONtZ _ ,. o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ONE ITEM �1PERENTLY CLOSED SITE I_&❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE00 IV 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILI ITE NAME L CARE OFA DRESS INFORMATION AVI ADD ✓ Ih 1,n NEAREST CROSS STIR ET LJ PAIMEMP 0 STATE I,GD& U Zi1V{�- CGAPO 717 ❑ LoC&_At;E,0 ❑ KDERALAGRICY CITU NAME_ STATE INGNIDU/L ❑ IAU#.WITH A CA 2 CODE SITE a.`TH AREA CODE �'/ TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑I�q PROCESSOR ✓Bax if INDIAN EPA ID n l/[_i 9 Y ❑ I GASSTATION ❑3 FARM .LJ V11°" RESERVATION or of TAN## O TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE TOMIi n50. � 1C �c� .20 12-956 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to md,cate ❑ PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box lo,.dicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 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. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R AGENCY# FACILITY ID k M of TANKS N SITE Enl 0o CURRENT LOCAL FAOCILI ID N APPROVELT BY NAME PHONE M WITH AREA CODE PERMIT NUMBER 11/y,1, PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA CDE CENSUS TRACT# !!!14 ISORIOIBTRICT CODE BUSINESS FLAN FILED O VES NO � 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 INFORMATI�'ORCY, \ ORM A(3-2-88) ,�\J\ %Ile DATA PROCESSING COPY