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STATE OF CALIFORNO WATER RESOURCES CONTR BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° Io 711- COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5� w I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS IN ORMATI N 's /l CG�croo_ ccz- ' 3f _q_ ADDRESS Dn,� NEAREST CROSS SUIEET ❑ Bm Wxdxlx O PLGRTINOMLY ❑ WSTATE O I 7L! I n ❑ INDNIDUAL UNTY#GBICY 0 {..a.w1L CITY NAME4 o I I � STATCA ZIPf� �� SITE PHOQ �IAREA COOED� TYPEOFBUSINESS: F❑ 2 DISTRII-B-UUMR ❑4PRDCESSOR -/Box d INDIAN EPA ID # l•fl ❑ 1 GAS STATION ❑ 3 FARM THER RESERVATION or �T THIS TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) 1� PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE WITH AREA CODE u NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME SCOAZ4� CARE OF ADDRESS INFOR A710N � Sc� MAILING or STREET ADDRESS ^ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY IJFEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STq[E ZIPCODEPHONE p,WITH AREA CODE �� Ill. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME ^^ n n CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ 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. II. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #o1 TANKS at SITE LjHl = = I D I D 1 2 1) 1 D I cia 1 o CURRENT LOCAL ASCAGENCY FACITS LITY IDM IU APPROVED BY NAME PHONE p WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRAACT# SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE L� ^„ '� D ' J fb (_I d`0 YES NO /uP/1 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: 41S 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. I A(3-2-88) 0 DATA PROCESSING COPY •