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STATE OF CALIFORA WATER RESOURCES CONTRII BOARD 4 :- °°°°•, ��', FORM `A': UNDERGROUND STORAGE TANK PROGRAM SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE C'4^IFO FNP MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) o FACILITY/SITE NAME C CARE OF ADDRESS INFORMATION ADDRESS NEAREST GROSS STREET ✓Dow to ma¢ate ❑ PARTNERSHIP ❑ STATE AGENCY N ❑ CORPOWRIGN ❑ LOCALAGENCY ❑ FEDERAL AGENCY CITU NAME EJINDIVIDUAL FICOUNTYAGENCY cn STATE ZIP ODE SITE PHONE#.WITH AREA CODE 46 C CA S TYPE OF BUSINESS'. L_j STRIBUFOR 11 4 PROCESSOR I -/Box if INDIAN EPA ID a 1 GASSTATION E 3 FARM 5 OTHER RESERVATION TRUST LANDS or #of TANK's W YL.�� AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS'. NAME(LAST,FIRST( PHONE a WITH AREA CODE AM II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME , n / L'. D /✓1 c CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS 7 I/Box to intlicale ElPARTNERSHIP ❑ ATEAGENCYEl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCYCITY NAME T SIJ C^4 C, ST?/Q ZIP CODE PHONE a,WITH AREA CODE / �l Ca (0-LI p III. TANK OWNER INFO MATION & ADDRESS - (MUST BE COMPLETED) NAME T� 4 C CARE OF ADDRESS INFORMATION 14/ iT Se/I/��Ce MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY/� ❑ CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCYL' ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME C STATE ZIP CODE PHONE a,WITH AREA CODE T IV. LEGAL NOTIFICATION' AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. it. 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 If AGENCY# FACIHTYItD—* _ is of TANKS at SITE - � OO CURRENT LOCAL AGENCY FACILITY ID# '-'---- __ -T _ C APPROVED BY NAME PHONE#WITH AREA CODE l PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 a 3 r Q (J YES � NO � �G, ylp CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Sy; 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. 1 FORMA(3-2-88} It DATA PROCESSING COPY 0 S