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STATE OF CALIFORN191 WATER RESOURCES CONTROL BOARD „r W A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM " Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO COMPLETE THIS FORM FOR EACH F LITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 P TLV CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) d FACILITY/SITE NAME _� CARE OF ADDRESS INFORMATION I ADDRESS �� NEAREST CROSS STREET ✓ft toiMicale PARTNERSHIP 0 STATEAGENCY W U T 0 INTIVIDUAl10N 0 LOCAL-AGENCY AGENCY ❑ FEDERALAGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE l,c� e.�. CA q 6 �� - a TYPE OF BUSINESS x STRIBUTOR ❑ 4 PROCESSOR ✓B . 'INDIAN EPA ID # ❑ 1 GASSTATION 3 FARM ❑ 5 OTHER TRUSTYLANDS of ❑ N of TANK's AT TNIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS'. NAME(LAST,FIRST( PHONE#WITH AREA CODE ►� so - 7-35019 Sri NIGHTS. NAME(LAST,FIRSTI PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME w•_ '/ ` CARE OF ADDRESS INFORMATION Vrryr 7 MAILING or STREET ADDRESS ✓Box to intlicate Cl PARTNERSHIP Cl STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY C FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME J/�� [[ CARE OF ADDRESS INFORMATION (/VYWCi At7 MAILING or STREET ADDRESS ✓Box to mocate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.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. Ir if. ❑ 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 N JURISDICTION N AGENCY N FACILITY IDN N of TANKS at SITE al = = 141108 d0 1 b .2- CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Z 1 YES [-] NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY.If 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 ONLY. FORMA(3-2-88) le DATA PROCESSING COPY