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STATE OF CALIFORNit WATER RESOURCES CONTRO•OARD W. s FORM `A': UNDERGROUND STORAGE TANK PROGRAM _ _ o SITE FACILITY/SITE, INFORMATION and/or PE IT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Elr5 CHANGE OF INFORMATION 7 PERTLY CLOSED SITE ^y ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 96/ O" u: I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION AD �^ELSS '/ NEAREST CROSS STREET ✓go,brNub ❑ pggiNEPSNIP ❑ STPTE AGENCY K� ✓iI Irl. ` 2 6 S `y ❑ CORMTON ❑ LOCALAGENCY ❑ FEDERILAGENCY 1:1 INDIVIDUAL ElCOUNTYRGENCY CI NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE CA �If37` /S -�Zf 5Io0 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i1INDIAN/ EPA ID # ❑ I GASSTATION3FARM 5OTHER RESERVATION or ❑ If of TANK'Y ❑ ❑ TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,, Fes( '/PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME 7 M� IM CARE OF ADDRESS INFORMATION MAILING or STREET DDRESS Q y ✓ to indlcale 13 PARTNERSHIP STATE AGENCY Y Box O fD 5—/G ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME G 37S CGS STATE ZIP CODE / PHONE 4,WITH AREA CODE / OV 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION - MAILING or STREET ADDRESS ✓Boxt mdxata ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY El INDIVIDUAL ❑ 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. ❑ if. ❑ 111. ❑ 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 77 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY NFACILITY ID N _� N of TANKS al SITE z / � o o CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE &&12, 'S i PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE FILED YES NO >fi-�yi�g CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# ByW is THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLE$,S THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) • �'\/ DATA PROCESSING COPY