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STATE OF CALIFORNIA WATER RESOURCES CONTRO&ARD "" 0, a FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o S1FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' I y COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE & 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION QiasS - SCo f%Oms ADDRESS NEAREST CROSS STREET ✓ El PARTNERSHIPEl AGENCY ❑ CORPORATION Cl LOGEN 13 FEDERAL AGENCY '✓ J__ 1 11 INDNIDUk ❑ C1NINTrAGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE S*(_,�� CA la TYPE Of BUSINESS'. 2 DISTR4 PROCESSOR -/Box If INDIAN EPA ID N ❑ DISTRIBUTOR F—] X 01 TANK'# RESERVATION or 1A �-, p ❑ I GAS STATION AOM ❑ S OTHER TRUST LANDS ❑ I A V`_- AT THIS SITE 0 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE � 110,5sesco ,-(_ ao 4(0 -3 `135 NIGHTS'. NAME(LAST.FIR)I HONE p WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE Y WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME 1 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP COD O PHONE;`WITH AREA CODE_ III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) X^V f( NAME CARE OF ADDRESS INFORMATION S MAILING or ST ET ADDRESS ✓Ban to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. ❑ 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 N JURISDICTION# AGENCY II FACILITY ID k M of TANKS at SITE 0101010 CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE Y WITH AREA CODE PERMIT NU EFIPERMIT APPROVAL DATE PERMIT EXPIRATION DATE [LOLCATIONE CENSUSTRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDa � rA `� YES NO �PERMIT AMOUNT SUR ARGE AMOUNT FEE CODE RECEIPT# BY: 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 ONS FORM A(3-2-88) • • `J iti,�DG — tcA �`�