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STATE OF CALIFORNIA WATER RESOURCES CONTR04PBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM p � Ao SITE , C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; a o COMPLETE THIS FORM FOR EACH FACILITY/SITE `"ArFa Ry MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2<cHANGE OF INFORMATION ❑ 7 PERMANE TLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE W I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) w FACILITY/SITE NAME CARE OF ADDRESS #FORMATION v ty{ + Sh c YYl i Yj Y1�R ADDRESS M NEAREST CROSS STREET ✓Ba to iVVAe ❑ PARTNERSHIP ❑ STATE AGENCY Ja,U , I ' ❑ CAIRPORATION ❑ LOCAL El FEDERAL AGENCY INDIVIDUAL ❑ ❑ COONIYAGENCY CITY NAME Laces. STATE ZIP CODE SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box I INDIAN EPA ID It ❑ I GAS STATION F-13FARM 21 OTHER TRUSTYATION LANDSo ATTHISSITE lJ I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE ft WITH AREA77`O 0 /01 NIGHTS: NAME(LAST.FIRST) PHONE ft WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME f CARE OF ADDRESS INFORMATION 11Lk 0 MAILING or STREET ADDRESS ✓ROx to intlicale ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE ft.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box mirrd,cale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK 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 N JURISDICTION Al AGENCY N FACILITY ID N #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID k �ns�� APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# ODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED YES NO i PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: ITHIS FORM MUST BE ACCOMPANIED BY AT LEASj*R MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 11U\ISI FORM A(3-2-88) DATA PROCESSING COPY