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STATE OF CALIFORNIAWATER RESOURCES CONTROL HARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM = ' a Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 61 rw 0 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) F-� FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS I NEAREST CROSS STREET mlP,,dxali, ❑ PARTNERSHIP ❑ STATE AGENCY l"I 1 1 }�G - O�rn 11-3._ 4k11"SPATISH LOCALEl FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE a.WIT AREA CODE Man Cc c— Cq 9S 33(D C l✓\ TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a RESERVATION or #of TANK's / GASSTATION ❑ 3FARM ❑ 5OTHER TRUST LANDS ❑ ATTHIS SITE o EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE 1/l I — NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CC CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.la indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY 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 ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE a,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: L II. ❑ 111. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE ® I o I o Ia oid I I b 10 10 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE TF_x0 G PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE rCHECK* ATION CO�DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDC[ /4/� l r� J � C`I YES NO 1 a % cc 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 O FORMA(3-2-88) DATA PROCESSING COPY •