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STATE OF CALIFORNIP WATER RESOURCES CONTROL0ARD �j FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE /�j FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION P o COMPLETE THIS FORM FOR EACHF CILITY/SITE MARK ONLY ❑ 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 -7IZ3 co I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) cy) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 25w ZI& 6 C . � a �/ Cv 0 4��o� f.w lou ADDRESS NEAREST CROSS STREET ✓R 'o-A ❑ PARTNERSHIP ❑ STATE AGENCY ' t. R PAT1ON ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ✓°e / , ❑ INDIVIDUAL ❑ OOLi AGENCY CITY NAME STATE ZIP CODE SITE PHONE if WITH AREA CODE Is)40cCA 9saos si TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d P $SOfl ✓Box if INDIAN EPA ID # ❑ I GASSTATION 3 FARM 5 OTHER RESERVATION or N G #of TANK'a E] TRUST LANDS ❑ /� AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS'. NAME(FAST,FIRST) PHONE#WITH AREA CODE C v aeco u 9 L,,'A-) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE L111 N Al II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ? 2%q vim/ MAILING or STREET ADDRESS / ointlicate 11 PARTNERSHIP ElSTATE-AGENCY JV �� . �`• / �� CORPORATION 13LOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE S /v c,/cin CA S.pct III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �� ✓,`/ fv Lca MAILING or STREET ADDRESS ✓ io intlicate Cl PARTNERSHIP Cl STATEAGENCY o��qq ,pp CORPORATION 11 LOCAL-AGENCY ❑ FEDERAL-AGENCY ` V..J• ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE ��c-/ /-o C gsao IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ H. ❑ If. 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 3 9 = = 1 O 1 o / 17 3 Ll o 1 0 1 0 / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE b -47 Z_7Aa (a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO ❑ =�p�_ CHECK# PERMIT AMOUNT SURCHARGE 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 ONLY. FORM A(3-2-88) 0 DATA PROCESSING COPY 5__�'