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STATE OF CALIFORNIA WATER RESOURCES CONTROARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE fS�.P'E p�w.f,', WP. A Y O Cq LIFORN�.P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURErS- a I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SEE NAMECARE rr LA£ I (fCf)qC (c, OF ADDRESS INFORMATION CITY NAM E,�— � � �_�C_J'� ADDRESS�{r l O c) NEAREST CROSS STREET ✓ Box to indicate ElNDIVIDUALION El PARTNERSHIP ❑ STATE -AGENCY EDL L &JA6`ENCY Q COUNTY AGENCY FEDERAL-AGENCY,, CITY NAME S+I� PHONE #, WITH AREA CODE STATE CA CODE �saC� SITE PHONE #, WITH AREA CODE ---- TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 1 GAS STATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER ✓Box if INDIAN TRUSTVLANDS ATION or ❑ EPA ID # # of TANK's AT THIS SITE b EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE q WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE q WITH AREA CODE I NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME rn Cir IOU)� � �e�- CARE OF ADDRESS INFORMATION - MAILING fff o 1. TR ADDgox �I ✓ Box to indicate E]PARTNERSHIP ❑ STATE -AGENCY El CORPORATION ❑ LOCAL -AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAM E,�— � � �_�C_J'� STATE., /`S)j'� ZIP DE � � I � L PHONE q, WITH AREA CODE LIS I11. TANK OWNER INFORMi'ION & ADDRESS - (MUST BE COMPLETED) NAMErr// �, ^ ❑ �1 ,� lw CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CURRENT LOC AGENCY FACILITY ID # u� y ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE # WITH AREA CODE ❑ 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. ❑ If. el, 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 # JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE CURRENT LOC AGENCY FACILITY ID # u� y APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE 1 : CENSUS TRACT # SUPERVISOR -DISTRICT CODE q19 BUSINESS PLAN FILEDDATE YES ❑ NO ❑ FILED C65 Ial CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY: VOTHIS FORM MUST BE ACCOMPANIED BY AT LEAF RM A (3-2-88) 0 MORE TANK PERMIT FORM `B' APPLICATION(S), U►'""Q THIS IS A CHANGE OF SITE INFORMATION ONLY DATA PROCESSING COPY 9 j F-� N 00 (D