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j _ STATE OF CALIFORNO WATER RESOURCES CONTRAOARD yEA� o .M1 FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o ;l ' 'o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ ( NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 w I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CL C k i I L - C-0 cel . &Y ct 'i-f It ADDRESS NEAREST CROSS STREET ✓gylpigi¢N PAfliNEflSNIP ❑ STATEAGENGY 3 _ O IC C �4 �c_+7,_\ 1 COAP=70N ❑ LOCAL AGENCY ❑ FEDERAL AGEVCY J V ❑ INGIVIDUAL 11COHI AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE Lc1ci ( CA Z 09 33v 0__�-{1 TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ q PROCESSOR ✓Box if INDIAN EPA ID # ❑ I GAS STATION ❑3 FARMOTHER RESERVATION or ❑ - �^ #of TANK's � TRUSTLANDS L/ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) //�� PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE -t,( A__.LC -- - NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME RCARE-OFF ADDRESS INFORMATIOr lam' Ct1 MAILING or ET ADDRESS a ✓Box to md,i ,te El PARTNERSHIP STATE-AGENCY O UO ^ �� ❑ CORPORIVIDUAL ATIONCl COUNTY AGENCY 11 LOCAL-AGENCY ElFEDERAL-AGENCY INDCITY NAME Low STAT ZIP CODE PHONE#,WITH AREA CODE C) Szyl III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME Q ^ n CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to'mtlic.te ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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,I S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY# FACILITY ID R M of TANKS at SITE 3 0 0 -o5Ood v CURRENT LOCAL AGENCY UPI LITY ID# APPROVED BY NAME PHONE#WITH AREA CODE J ZPERPERMIT NUMBER IT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION ODE CENSUS TRACT#� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED4 alL 3QUl YES NO CHECKN 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(3-2-88) DATA PROCESSING COPY L