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STATE OF CALIFORNIA• WATER RESOURCES CONTROLB ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE FMARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERIIIANEEIR44JOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S U I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/ ENAME CARED ADDRESS INFORMATION MAILING or AREETi DDRESS✓ �� to CORPORATION [IC3intlicate ❑ PARTNERSHIP ElSTATE-AGENCY LOCAL -AGENCY FEDERAL -AGENCY C ❑ INDIVIDUAL ADDRESS �, /� /, '.�A / /E `(�- (L((�((-✓ Y(///�/) CIN NAME NEA ST CROSS STREET ✓�aCO P PATIO .$ fAFPOAATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ STATE ❑ LOCAL AGENCY ❑ FEDERAL- AGENCY ❑ COUNIY-AGENCY CITY NAME LOCATION CODE STATE 0 E PHO EA CODE n Gl�l C� PERMIT AMOUNT CAD FEE CODE RECEIPT# �� N TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PA ESSOA */Box it INDIAN EPA ID # GAS STATION ❑ 3 FARM 5 OTHER TRUSTRESERYATION LANDS o ❑ DJ(� ('miq E} ySlE d1 D 9, EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) L)DAYS NAME (LASE FIRST) HONE p WITH AREA CODE DAYS. NAME (LAST, FIRST) / RHONE p WITH AREA CODE l OS KSS o 82,3 D #4 NIGHTS: II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME (LAST, FIR ) - PHONE#WITH AREA CODE NIGH/j^S- NAME (LAST, FIRST) NAME 16 e DARE OF ADDRESS INFORMATION MAILING or AREETi DDRESS✓ �� to CORPORATION [IC3intlicate ❑ PARTNERSHIP ElSTATE-AGENCY LOCAL -AGENCY FEDERAL -AGENCY C ❑ INDIVIDUAL ❑ COUNTYAGENCY CIN NAME STATS ZIP 7)Q PHONE p. WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME JURISDICTION # CARE OF ADDRESS INFORMATION FACILITY ID # # of TANKS at SITE MAILING or STREET ADSS � � 7 9CITY C ✓ x to intlicate LJ [I LOCAL -AGENCY❑ COUNTY AGENCY El INDIVIDUAL ❑ STATEAGENCY ❑ FEDERALAGENCY N PERMIT APPROVAL DATE STATE ZIP CODE PHONE #, I AREA CODE LOCATION CODE CENSUS TRACT p SUPERVISOR-DIBTRICT CODE BUSINESS PLAN PILED YES NO D FIL 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE CU ENT LOCAL AGENCY FACILITY ID # CTA r; b APPROV D BY AME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT p SUPERVISOR-DIBTRICT CODE BUSINESS PLAN PILED YES NO D FIL CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST)• OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLL- FORM A (3-2-88) DATA PROCESSING COPY HIS IS A CHANGE OF SITE INFORMATION ONLY.