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STATE OF CALIFORNIN OBOARD WATER RESOURCES CONTR ��E�`"°'"'`�' FORM 'A': UNDERGROUND STORAGE TANK PROGRAMxi SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT PRI CHANGE OF INFORMATION ❑ 7 PERMANENTLY C SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE ! Ib I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY TE NAME CARE OF ADDRESS INFORMATION 2.C- l i N ADDRESS � /� -_ NEA E TCROSS TREET ��✓�W tomi�cae ❑ PARTNERSHIP Cl STATE AGENCY a) J`(/^ ,�(�/AV�(`�J'_ 21000RPORATION ❑ LDCPI AGENCY ❑ FEDERAL AGENCY 0 INDIi 0 03UNIYAGENCY CITY NAME STATE ODE SITE PHONE#,WITH AREA CODE N CA 9 2--05_ --O TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BOX if INDIAN EPA ID# # O of TANK'# E] 1 GAS STATION [:] 3 FARM ®'�THER TRUSRESETYLANDS ATION Or❑ O AT THIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYSNAME(LAST,FIRST PHONEI#'W,IT�REA CODE L , Y �5s pl YS `�701 NIGH NAME(LAS FIRST PHONE p WITH AREA CODE NIRTS NAME(L T, RST) PHONE p WITH AREA CODE s - -3 -y6 II. PROPERTY WNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME L � CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME S CARE OF ADDRESS INFORMATION 1 MAILING or STREET ADDRESS ✓Be.to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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. &J- it. ❑ 111.❑ 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 If #of TANKS BI SITE ® 6D / zZ1 1010101 / 1 CURRENT OCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE SSO PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED /1 YES NO CHECK# PERMIT AMOUNT dt•/ SURCHARGE AMOUNT FEE CODE RECEIPT# BY: I„ 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 SB) 10 • DATA PROCESSING COPY L)S-