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STATE OF CALIFORNif WATER RESOURCES CONTR BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/ FTE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMITANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAMEJ CARE OF ADDRESS INFORMATION // ADDRESS NEAREST CROSS STREET ✓ rbrak D PMTNERSHP 0 STATE AGENCY 0 INCDMDUALION D WUNTYAGBIIX D FETIFAAL-AGENCf CITY NAME STATE ZIP CODE SITE PHONE*,WITH AREA CODE Fon CA l Sal - Plo��6S/ TYPE OF BUSINESS: ❑ 3 DISTRIBUTOR ❑ /PROCESS6R ✓Boz it INDIAN EPA ID x N MTANKY ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ION GT ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE 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 cc-- CARE OF ADDRESS INFORMATION dun �b uir Z,m Cv MAILING or STREET ADDRESS ✓ xto iMicate D PARTNERSHIP D STATE-AGENCY ,O CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY -7/ 0 INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE*.WITH AREA CODE 's-{v C-/cam-, C-,) I �_)O -S,S i III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box to iMicate 0 PARTNERSHIP D STATE-AGENCY 0 CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL 0 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. MP 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 N JURISDICTION N AGENCY N FACILITY IDN Bol TANKS M SITE M = = lololl � o o a CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE*WITH AREA CODE 5/n-),? 0 -2 3 PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION ODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DATE FILED ��J YES NO 7 CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: C_"73, 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) 0 0