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. o STATE OF CALIFORA WATER RESOURCES CONT BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMow SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE W ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CD IV I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) p) FACILITY/SITE NAMEMaC II //�! 1 CARE OF ADDRE NFORMATIO Lc V p�A.- Yll L I ADDRESS NEA REST CROSS STREET ✓BN lodNirale 0 PARTNERSHIP 0 STATE AGENCY O L ORPORATION ❑ LOCAL AGENCY ❑ FEDERAL ❑ INDIVIDUAL 0 COUNTY AGENCY CITY NAME1 STATCA ZI$.�ODE_ SITE��T3RO C�E TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID p p of TANK'e I�I�� RESERVATION or �--^�� AT THIS SITE ❑ I GAS STATION ❑ 3 FARM L� CHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE k WITH S AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE �� sc- l- c .e�.�-lam zmi3 � ©3�S NIGHTS' NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAS`T,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION lzc- 1 h MAILING or STREET ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY ADDRESS L 3 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERALAGENCY r2Yt fuY .B'IKDIVIDUAL 0 COUNTY-AGENCY CITY NAME 11 STATE Zp CODEs PHONEONE 0 WITH RHEA O ? \i�' R 3 III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION C LOCAL-AGENCY 0 FEDERAL AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE p,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. ❑ If. 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 k JURISDICTION p AGENCY p FACILITY ID p pat TANKS al SITE CURRENT LOCAL AGENCY FACILITY IDD APPROVED BY NAME PHONE It WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE E E CENSUS TRACTp SUPERVISOR-DISTRICT CODE BUSINESSPSN FILED NGMA PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k 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(3-2-58) • DATA PROCESSING COPY