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STATE OF CALIFORNIP WATER RESOURCES CONTROSOARD r, o i rhp FORM `A': UNDERGROUND STORAGE TANK PROGRAM .a SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; COMPLETE THIS FORM FOR EACH FACILITY/SITE "FOR MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM CLOSED SITE 1--► ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 80 I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) Cn A FACI TY/SITE NAME CARE F ADDRESS INFORMATION MA A RES ,x , NE EST CROS REET ✓60 to route ❑ PARTNERSHIP ❑ STATE AGENCY y O-7 C 11 El 11LOGLAGENCY OEA LAGEN 1. V�' '"^F ElINDIVIDUAL ❑ AL COONN AGENCI CITyNE / i STATE ZIP CO E / SITE PHONE N.WITH AREA CODE \\JJ `!'�Arn`�7`/nA�Y'�' CA ��z.OS �' I - Oc TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCEWR I ✓Box if INDIAN EPA AIID a /l ' �L ❑ 1 GAS STATION ❑3 FARM S OTHER TRUSTVLANDS ATION Or ❑ CAIC) 1J 0/b LN �/ ATIt HISTANSITE /� AT THISSITE (/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE W WITH AREA CODE DAYS'. NAME(LAST,FIRST) PMWITH AREA CODE u� R? (- ? D,1 ? SJA J A NIG NAME(ILAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE 4 S b S A II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME �- CARE OF ADDRESS INFORMATION 5LA ,14-z - MAILING orSTREET ADDRESS s/Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE A,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl 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. ❑ 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 M JURISDICTION M AGENCY# FACI ID# #of TANKS at SITE Dal = Lfaa3 - W � o CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY N E ONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE I CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OAT FILE ,b'� r YES NO Tf' CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 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. FORM A(3-2-88) of I DATA PROCESSING COPY 40