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OSTATE OF CALIFORN WATER RESOURCES CONTROARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El7 PERMANENTLY CLOSED SITE ="a" ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE w I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS r NEAREST CROSS STREET ✓Bar to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY El CORPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY A lv r 1) � (fiJ/,�r/ ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE :5W41 CA �'Z�e' Z49 �f� d J"V/ TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box If INDIAN EPA ID u #of TANK's ❑ 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUSTVATION LANDS dr ❑ AT THIS S1TE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS, NAME( ST,FIRST) PHONE H WITH AREA CODE NIGHTSNAME(LAS ,FI ) PHONE It WI,T,H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME .5�ez z /_ r CARE OF ADUAESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME fes,,, STATE ZIP JE t PHONE q WITH AREA CODE SS7�! �I O /V/ III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME51�� / (/,./* CAR OF ADDRESS INFORMATION nd- MAILING or STREET ADDR I-- %/Box to indicate ElPARTNERSHIP ❑ STATE-AGENCY (/ 11 ' 11CORPORATION 1:1 LOCAL-AGENCY 1:1 FEDERAL-AGENCY _ !/ �� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME n � STATE _A ZIP C �� PHONEn,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. ❑ 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(PRIN7ED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE lolol 1I z-I LLOI 10 o a' CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE e" ;� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 0 YES ❑ NO r CHECK N 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 ISA CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) 'W to DATA PROCESSING COPY 0