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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD <EP` FORM `A': UNDERGROUND STORAGE TANK PROGRAMo) SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r` Y0 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �.s fto L)o m er L, / U6/ r r\) ADDRESS NEAREST CR SS STREET ✓Boy�w ale ❑ PARTNERSHIP ❑ STATE Oea,,ATlGN D LOCALAGENcv D FEDENTAGENCY D INDIVIouAL D COUNTYAGENCY CITY NAME /1 STATE ZIP CODE SITE PHONE# WITH AREA CODE 4�// CA 53 �� -V.) TYPE OF BUSINESS. ❑ DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # RESERVATION or #of TANK's ❑ 1 GAS STATION ❑ 3 FARM R TRUST LANDS ❑ Al/(rn'� ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PH NE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 9 WITH AREA CODE P 6 / S�/`1 NIGHTS'. NAME(LAST,FIRST) HONE#WITH AREA CODE NIGHTS. NAME(LAST FI T) HONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION keine otrLf� MAILING or STREET ADDRESS ✓Box to Indicate D PARTNERSHIP ❑ STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMEAD %J N �� —� CARE OF DRESS INFORMATIONIIWPJO / n — e 4. MAILING or STREET ADDRESS B intlicaPe D PARTNERSHIP D STATEAGENCY /7, CORPORATION ❑ LOCALAGENCYD FEDERALAGENCY /'i C/ D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k.WITH AREA CODE C/ I3(�/a IV. LEGAL NO IFICATION 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# AGENCY# FACILITY ID# #of TANKS at SITE ad I A 1 ao 0 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE /ASO N/ PERMITNUMBER PERMIT APPROVAL DATE P EMIT EXPIRATION DATE R IL LOCATIONC E CENSUS TRACT ### SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE O 3,o U Q--/ YES E] NO � 7v CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Ar Y: 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. Q.\ FORM A(3-2-88) \\\\V\1v 0 DATA PROCESSING COPY 0