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f' ' 41 STATE OF CALIFORMA WATER RESOURCES CONTRO OARD `F f�R[R4 hs �a FORM `A': UNDERGROUND STORAGE TANK PROGRAM Y T SITE C' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH_! !CITY/SITE CS L,Fa 00 . ` MARK ONLY El1 NEW PERMIT ❑3 RENEWAL PERMIT' CHANGE OF INFORMATION ❑ 7 PERMANENTLY CI-OSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT' ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAM CARE OF ADDRESS INFORMATION �/tin � .-�5�,�''I✓� L�✓�/�S ;� ADDRESSNEAREST CROSS STREET BOK dale ClPARTNERSHIP ❑ STATE-AGENCY ,J RATION ❑ LOCl/-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE L CA .538 47 —� /� TYPE OF BUSINESS: EPA ID # ❑2 DISiR18UTOR ❑4 PROCESSOR RESERVATION or _ A 01 TANK'S ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ElAT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) _ DAYS: AM (y�ST FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Moll-, , Gr ��Z—��/S� y a NIGHTS: NAME(LAST.FI T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ) 11. PROPERTY OWNER INFORMATION &ADDRESS —:(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION c MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE jY If III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ) ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ' ZIP CODE PHONE#,WITH AREA CODE iF il, IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDREW SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ III.❑ THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THEff ST OF MY KNOWLEDGE,IS TRUE AND CORRECT. r APPLICANT'S NAME(PRINTED&SIGNATURE) N DATE Y j LOCAL AGENCY USE ONLY COUNTY M JURISDICTION 0 AGENCY A I FACILITY Ila M N o1 TANKS at SITE- d L-d o I o I i�l I r711 I. J CURRENT LOCAL AGENCY F CITY IDA APPROVED BY NAME; PHONE A WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE C LOCATION CmDF.,.� CENSUS TRACT A SUPERVISOR-DIS ICT CODE BUSINESS PLAN FILED p DATE FILED 7 YES,❑ NO ❑ CHECK A PERMIT AMOUNT SURCHARGE AMOUNT i FEE CODE RECEIPT A BY: of THIS FORM NAT BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM RBS APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL �FM A(3-2-88)