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STATE OF CALIFORNO WATER RESOURCES CONTR*OARD ;y �,°°•� r"A FORM `A'; u UNDERGROUND STORAGE TANK PROGRAMQ SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EA EH FACILITY/SITE FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ P INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ,vk IrflC/J� n 5 LC YC,,aLS'7 t ADDRESS /, � NEAREST CROSS REET ✓Bax 10Wule 11PARTNtMIF 1:1 STATE-AGENCY 2- L�1 G/, ❑ OORPDRATION ❑ -AGENCY 1:1 FEDERAL-AGENCY Y-� _ GL GL LEI INDIVIDUAL 12 CDt1NTY-AGENCY CITY NAME _ STATE ZIP C E SITE PHONE#.WITH AREA CODE 9�0 z CA TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 ROCESSOR ✓Box it INDIAN EPA ID # Not TANK's 1 GA5 STATION 3 FARM 5 OTHER RESERVATION 4r ❑ ❑ TRUST LANDS ❑ 1AT THIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS, NAME(LAST,FIRST)ll PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LASt,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATIpN MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ClLOCAL-AGENCY ElFEDERAL-AGENCY-2--2, -2 �i �� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 1A I --A , Tsz -2 III. TANK OWNER INFORMATION & ADDRESS -- (MUST BE COMPLETED) NAME 5 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate [] PARTNERSHIP ❑ STATE-AGENCY 11 CORPORATION ❑ L CAL-AGENCY ❑ FEDERAL-AGENCY l Z 2- L ❑ INDIVIDUAL OUNTY-AGENCY CITY NAME STATE ZIP CODE I PHONE#,WITH AREA CODE 61? , .2- hZI 9) IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ II. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE ERI I I El EI I I LLI--, I .3 7 3 10161 Q= CURRENT LOCA AGENCY FACILITY IDM APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / D/ y YES L_l NO 0 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ORM A(3-2-FR)