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STATE OF CALIFORNP WATER RESOURCES CONTROBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM �m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z COMPLETE THIS FORM FOR EACH FACILITY/SITE ,H 1 G C9l,v OPS FMARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Tj' __4 I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) co FACILITY/SITE NAME D x CARE OF ADDRESS INFORMATION W A r T�Gcsn A ADDRESS NEAREST CROSS STREET ✓3p,to idigte 0 PARTNERSHIP 0 STATE AGENCY vi Sirmif 0 CORP"'iION 0 LOCALAGENCY 0 HOERALAGENLY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STA ZIP CODE SITE PHONE#,WITH AREA CODE sh%K4N CA 95arm TYPE OF BUSINESS: 2DISTRIBUTOR ❑ 4PROCESSOfl /Box if INDIAN EPA IDP ❑ 1 GASSTATION ❑ 3 FARM 5 OTHER RESERVATION or ❑ - M of TANI TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE It WITH AREA CODE 'SlkQ U� '4009 '/ —�d�/ NIGHTS. NA (LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE it WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to'mdic.t. 0 PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL Cl COUNN-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ♦r MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCYCl FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION S AGENCY k FACILITY ID N If of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DgTE FILED 23 . '322- YES NO D f CHECK R PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY OK THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TAKE PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL`(A , FORM A(3-2-88) G� \\v 0 DATA PROCESSING COPY