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STATE OF CALIFORNIAO WATER RESOURCESCONTROROARD yf r' JM1 f y' FORM `A': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/ r PERMIT APPLICATION IZO COMPLETE THIS FORM FOR EA7H FACILITY/SITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERWANFN LY CLOSED SITE I"A' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) C ' FACILITY/SITE NAM (e- „ O CARE OF ADDRESS INFORMATION f L An�Xn 1 LQ ADDRESS NEAREST CROSS STREET eo.ai�auN Cl PARTNERSHIP 11 STATE AGENCY COBPORAIION ❑ LOGAL-AGI ❑ FEDERAL-AGENCY ❑ INDMDUN ❑ COUNTY AGENCY CITY NAME S-TP -I STATE ZIP CODE SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS: F—] 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a rJ/ - #of TANK's 1 GAS STATION ❑3 FARM ❑ S OTHER TRUST VLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA E(I-AST.FIRST) PHONE p ITH AREA CODE DAYS: NAME(LAST,FI T) PHONE It WITH AREA CODE V_ Zo , 6 —6i� awIAt NIGHTS: NAME(LAST,QST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,F T) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESSax to intlicate 11 PARTNERSHIP ElSTATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 11,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF DRESS INFORMATION MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE If,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. IK it. ❑ IN.❑ 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 CO�UNTY## JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE Y# CURRENT LOCAL AGENCY FACILITY ID �' APPRO'VEED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE �/ryy PERMIT EXPIRATION DATE LOCATION CODE CENSUSI$ACT#_ SUPERVISOR-DI TRICT CODEC U BUSINESS PLAN FILED ❑ DATE FILED // (-7zf( o /'/v^ YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(4)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 LY, FORM A(3-2-88) DATA PROCESSING COPY