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STATE OF CALIFORNIA* WATER RESOURCES CONTROIWARD '` or. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ Z INTERIM PERMIT- ❑ N AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 33 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 2 / r J - <br /> ADDRESS NEAREST CROSS STREET ✓ ❑ PARINFASiP ❑ STATE AGENCY <br /> �S�O s' / .�� ❑ NDNIDIAL ❑ LOCAL <br /> WIW1YAGBILY ❑ RTYAAL-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE Y,WITH AREA CODE- <br /> 7-,—a <br /> ODE <br /> T`ac CA 95-3 /, <br /> TYPE OF BUSINESS: ❑p DISfRl8UTOR ❑ A PROICEM I ✓Bok it INDIAN EPA ID N <br /> ❑ 1 CJS STATION ❑ 3 FARM OTHER TRUSTTYAT iHI8 SISI <br /> LANDSSERVATION Or ❑ t W T S TE o <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE <br /> { ,(� 3r- spa Tumes Sessip a-o9- 3S -��'� <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inoicele ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Op ❑ CORPORATION 11LOCAL-AGENCY11 FEDERAL-AGENCY <br /> OX 1/3 - - _ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> — <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) EX7- C/o <br /> NAME CARE OF ADDRESS INFORMATION - <br /> _ -SC/PLa as'7- <br /> MAILING or STREET ADDRESS ✓Box to inNlcele ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND SILLINO: I. II. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCYLI FACILITY 10 S t of TANKS at SITE <br /> 3 9101 a 1,2 1 01 o I D Ij <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL GATE PERMIT EXPIRATION DATE <br /> LOCATIONCODE CENSUS TRA(C�TN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O� �O 3 0� v YES r] NO l <br /> CHECK N PlgY1T AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> - n <br /> 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. <br /> �FORM A 13 2 Wfl <br />