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STATE OF CALIFORNI.0 WATER RESOURCES CONTROROARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION 07 MARK ONLY ONE ITEM M 2 INTERIM PERMIT F-14 AMENDED PERMIT 0 B TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS .-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION FACILITY/SITE NAME CO i 1 NEAREST CROSS STREET ADDRESS I f we_ STATE ZIPCODEE CITY NAME TYPE OF BUSINESS: —//F_� 2 DISTRIBUTOR I] 4 PROCESSOR RESERVATION it INDIAN or ❑ 1 GAS STATION [:] 3 FARM 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) DAYSNAME (LAST, FIRST) PHONE N WITH AREA CODE V" D I 6 oq �fb�- NIGHTS'. NAME (LAST. FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (I NAME _ c1 r 1— 1 . — _ _ MAILING .,STREET ADDRESS III. TANK OWNER INFORMATION & ADDRESS - NAME a a v� MAILING or STREET ADDRESS CITY NAME moo. -- Naf TANK's t 5E0. W AT THIS SITE EMERGENCY CONTACT PERSON (SECONDARY) DAYS'. NAME (LAST, FIRST) PHONE # WITH AREA 000E zbQ NIGHTS. NAME ILAST, FIRST) PHONE WITH AREA CODE C4ll[00.��P LOBED SITE O `V W PARTNERSHIP 0 STPEAGENCY LOCAL AGENCY 0 FEDERAL AGENCY SITE PHONE 4, WITH AREA CODE EPA ID # Naf TANK's y AT THIS SITE EMERGENCY CONTACT PERSON (SECONDARY) DAYS'. NAME (LAST, FIRST) PHONE # WITH AREA 000E NIGHTS. NAME ILAST, FIRST) PHONE WITH AREA CODE ST BE COMPLETtU CARE OF ADDRESS INFORMATION ✓Box to indicate ❑ PARTNERSHIP 0 STATE -AGENCY 0 CORPORATION Cl LOCAL -AGENCY 0 FEDERALAGENCY O INDIVIDUAL 0 COUNTY -AGENCY STATE ZIP CODE PHONE WITH �� BE COMPLETED) CARE OF ADDRESS INFORMATION Box to indicate 0 PARTNERSHIP 0 STATEAGENCY CORY OUALON El COUNTY AGENCY 0 LOCAL 0 FEDERAL -AGENCY 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. El THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANT'S NAME (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY F -7 -- DICTION N AGENCY p FACILITY IDN N of TANKS al SITE OD�a.3eteneMDY FACILITY ID # APPROVED BYNAMEPHONE N WITH AREA CODE V V '� ® PERMIT EXPIRATION DATE PERMIT NUMBER PERMIT APPROVAL DATE LOC ATY N CODE CENSUS TRACT N� SUPERVISOR -DISTRICT CODE BUSINESS PUN FILED ❑ DATE FILED 3 YES NO L / CHIPERMIT 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) DATA PROCESSING COPY 5