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STATE OF CALIFORNIA WATER RESOURCES CONTROL S FORM `A': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w r, COMPLETE THIS FORM FOR EACH FA ITY/SITE MARK O LY ❑ 1 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 a •0 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION e /YJ I-a YM N ADDRESS NEAREST CROSS STREET ✓Bm la ❑ PA6TNERS4IP ❑ STATE AGENCY ❑ TION ❑ LOCAL AGENCY ❑ FEDEMLAGENCY 5 CC / DIVIDUAL ❑ COUNIY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE (F5 Cc, (oCA 9573,�O TYPE OF BUSINESS: ❑ 2 D IBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID # RESERVATION or #of TANK's ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ u(L AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODEJ DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -'Y - ✓Bo intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION u✓C c9- MAILING MAILING or STREET ADDRESS ,✓eo 0 intlicale 11 PARTNERSHIP [ISTATE-AGENCY 11�2ORPORATION ElLOCAL-AGENCY E3FEDERAL-AGENCY L9- INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. Fr 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It AGENCY# ITY ID# If of TANKS at SITE 3 ol O v v / C 0 A AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA�TAION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED Y -6- YES NO � CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: a� 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 ONL4��\ FORM A(3-2-88) /\/\ DATA PROCESSING COPY