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.... _ ,_ ..rR. ...AY.... r.,.-ewrW...,.. .....-.�.......,. ,-T•T—' .., .q,..�,,,.�ogt<. ^�gl�{,ew.w�lsr-.. . t STATE OF CALIFORNI10 WATER RESOURCES CONTROROARD W FORM `A': UNDERGROUND STORAGE TANK PROGRAM " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o E COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1"'• ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I-1 � L FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) C" OD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION r e___4� ADDRESSNEAREST CROSS STREET ✓B irate 0 PARTNERSHIP 0 STATE AGENCY S /D 4 � RMRATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY 1` i ❑ INDIVIDUAL ❑ COUNIY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE 1 -AC-y CA 5 TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID # #of TANK'B RESERVATION or E] 1 GASSTATION ❑ 3 FARM THER TRUST LANDS ❑ (}1'�.Q� AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE 01,4 11PP IS' - S NIGHTS: NAME(LA FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION L- .E: or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP C STATE-AGENCY ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME DARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate 0 PARTNERSHIP 0 STATEAGENCY ,/� F�j 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY y I LJ 1 C , 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAM Sulo-_ I00 STATE ZIP CODE PHONE#,WITH AREA CODE �I CPT —i �2�- ^2 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ 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 If of TANKS at SITE 3 � 3 19 I CURRENT LOCAL AGE ILITY 10 00A PROVED B PHONE#WITH AREA CODE PERMIT NUMBER 1•C�„U AL GATE PERMIT EXPIRATION DATE [CLHECK# CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED YES NO ❑ ,�S IPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 1, 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIJONL \\U FORM A(3-2-88) • • DATA PROCESSING COPY