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w: ALIFORNI1 WATER RESOURCES CONTROPBOARD of STATE OFC P \SA FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE C9(jF�RNxP MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENXt`-5t6SED SITE 6+: ONE ITEM ❑ 2 INTERIM PERMIT 1:14 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE // I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITj NAME <<\1�w�""_ �/.' _n / CARE�ADDRESS INFORMATION k i.� ADDRESS �1w NEAREST CRO STREET ✓ oxtoindicate ElPARTNERSHIP ElSTATE-AGENCY 3 3(/ tew CORPORATION 1:1LOCAL-AGENCY ❑ FEDERAL-AGENCY JJ ��L (�(!1'N- (/G J�9/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE LIP CODE SITE PHO E#,WITH AREA CODE &ebl CA q_' f 16 1 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4,PROCESSOR I ✓Box if INDIAN EPA ID # ❑ ESE I GAS STATION ❑ 3 FARM �5 OTHER TRUSTv AATION NDS of ❑ "'A-000111(.1 Z #of AT THHISIS SITE d EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME ST,FIRST) ONE#WITH AREA CODE DAYS: tE(LAST,FIRST) PHONJ� 1AH AREA CODE NIGHTS: NAME(LAS ,FIRST) PHONE q WITH AREA NIGHTS:Cpl E(LAST,FIRST) PHONf�N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) J NAME CARE OF ADDRESS INFORMATION MAILING or rTFfEET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or TREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AN®"BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 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 O o FE CURREN��AGENCY FACILITY ID# APPROVED BY NA PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE 6JG/' PERMIT EXPIRATION DATE LOCATION DE CENSUSCT SUPE�L�SOR RICT CODE BUSINESS P S N FILED NO DATE LED , JF el 2 CHCCECKK/�/i# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# (/l// BY: 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. FORM A(3-2-88) DATA PROCESSING COPY