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STATE OF CALIFORNP^ WATER RESOURCES CONTROCBOARD f FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u` " SITE ,-r FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I"a ONE ITEM ❑2 INTERIM PERMIT ❑d AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 00 0(,T0) I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION no o Q TrCLC r' a Urj�) � cz ADDRESS NEAREST CROSS STREET ✓Box lDipiCale ❑ PARfNERNtlP SfATEAGENCI O Imo, ❑ fgPD0R4ilON ❑ IOGI-AGENCY ROERIL-AGENCY Al J1 �-N5wl0uk ❑ CDAM-AGENCY CITY NAME STATE ZI O SITE PHONE k WITH AREA CODE Lod ( CA U 09 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓BOX if INDIAN EPA ID N ❑ RESEVATION I GAS STATION [—] 3 FARM ,QJ OTHER TRUST LANDS or ElN of TANK'# AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRAM PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE IVB (Q� n r4cvk )-093b Q 3()"� NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(I-AST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS 6�✓Bow�o to indicate 0 PARTNERSHIP ❑ STATE-AGENCV L�j .^I�J�DORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME O STAT GOD PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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. ❑ 11. 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N AGENCY M FACILITY ID# N of TANKS at SITE ® Ob 3 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE p CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDYES ❑PERMIT AMOUNT SURCHARGE AMO TRECMUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. rS) J \\�I '-aw DATA PROCESSING COPY 'ai