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STATE OF CALIFORNS WATER RESOURCESCONTRO*OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u ' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z L COMPLETE THIS FORM FOR EACH FACILITY/SITE `+ciro �r 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I—& ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C ICI I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION S ADDRESS NEAREST CROSS STREET ✓lyxyj� 0 P��IP 0 STAT_pGENU. CAAPORA004 0 LOCAL-AGENCY ❑ PWIXAGENCY 13INDNMAL 0 wuKrv-AOBNcr CITU NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE CA S .2oISM TYPE OF BUSINESS: ❑p DISRiIBUTOR ❑ 4 PROCES=RES'E0RXVL'ATION INDIAN EPA ID # ❑ 1 GAS STATION ❑ 3 FARM HER or - If TANK'# ANDS ❑ _ A7 THIS SITE ' EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA COOL e� C 20 fi REAS 1 NIGHTS: NAME LAST FIRST ( ) PHONE p WITH AREA CODE NIGHTS: NAME(IAST, ) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ` CARE OF ADDRESS INFORMATION MAILIIIN\TGor STREET ADDRESS ,/GM ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY -U 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 1:1 INDIVIDUAL 0 COUNTY-AGENCY CITY NAM STATE- ZIP CODE PHL-O�N,E#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME k F CARE OF ADDRESS INFORMATION MAILINGor STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ��00 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE I'PHONE 11,WITHAREACODE6H —a 1 953 36cvi �1 c IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ 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 If o/TANKS at SITE I f CURRENT LOC AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE —I=201 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT If SUPERVISOR-D STRI CODE BUSINESS PLAN FILED DATELij 9 YES E] NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNTFEE CODE RECEIPT# I 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. 1l FORM A(3-2-BB) _ �\l DATA PROCESSING COPY I'✓ J