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i t, STATE OF CALIFORNI/, WATER RESOURCES CONTROL __ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM =� � m o f SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION j COMPLETE THIS FORM FOR EACH FACILITY/SITE Cy'FORi�p MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT I�Cf 5 CHANGE OF INFORMATION [:]-7 PE ENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT JJ1�❑l 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION IND R UA - STO Ck vtj & ADDRESS _ NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ' El CORPORATION ❑ LOCAL-AGENCY El FEDERAL AGENCY 0 V/ e ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMESTATE ZIP CODE SITE PHONE At,WITH AREA CODE 57414 / CA SSD TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR v/Box if INDIAN EPA ID # RESERVATION or #of TANK's ❑ 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: ME(LAST,FIRST) i PHONE#WITH Q ACO E DAYS: NAME(LAST,FIRST PHONE#WITH AREA CODE %VDU Q ve G✓ 2VI- V66-693'2— NIGHTS: NAME(LAST,FI T) PHONE#WITH AREA CODE NI HTS. NAME(LAV1,FIRST) PHONE#WITH AREA CODE (Ir k It t7 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME 7 CARE OF ADDRESS INFORMATION S6-)'hQs MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ^ �� CARE OF ADDRESS INFORMATION MAILING or STREET'ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. EK 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# AGENCY# FACILITY ID# #of TANKS of SITE DE a � L4�Lavt Yl CURRENT LOCAL AGENCY FA ILITY ID# / APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOq-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 01 13 a V `�O YES � 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 INFORMATION ONLY. /FSO A(3-2-88) I DATA PROCESSING COPY irl