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STATE OF CALIFORNIA• WATER RESOURCES CONTROL �s FORM 'A': r � UNDERGROUND STORAGE TANK PROGRAM - I P� FA ALL SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATI COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ Gy LOSER SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / 5Y7 ul I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) to FACILITY/SITE NAME CARE OF ADDRESS INFORMATION \1AMPrP & 6P45-4 L ADDRESS 7 NEAREST CROSS STREET at to indicate 0 PARTNERSHIP ❑ STATE AGENCY / t�(�R /_ C, L ✓� ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDEAALAGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE p,WITH AR 41-9 7 CA TYPE of BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR '/Box if INDIAN EPA ID p RESERVATION or K of TANK's ❑ 1 GASSTATION [:] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE tipfn��o/d ob 209-y6z '�/9Z7 Q/Z y�S /a NIGHTS. NAME(LAST,FIRST PHONE p WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S A-w-c MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION 0 LOCALAGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONEY 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION k AGENCY N FACILITY ID M R of TANKS at SIT ID 6 7 6, o � CURRENT LOCAL AGENCY FACILITY ID 00 <_ APPROVED BY NAME PHONE N WITH AR �/ �J PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L TION C7013E CENSUSTRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 11y y YES NO —2K M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N by: DQ THIS FORM MUST BE ACCOMPANIED BY AT LEA&OR MORE TANK PERMIT FORM 'B'APPLICATION(S), SS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) DATA PROCESSING COPY