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STATE OF CALIFORN* WATER RESOURCES CONTRII&OARD I FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to - COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•aw�`%� MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM OSE SITE Iii ONE ITEM p INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE - -4 i1 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACT TY/$ITE NAME ^ • _A_ _ CARE OF/�RESS INFORMATION AT F�fx{�.yBB7(�`/mow✓) NNE$/TCP STRE ✓Bmkiddaa ❑ PAUNMW 0 STATEAI h. ❑ COMPATEN ❑ LOI AGDO FFDEWl FNGY Cl iNDMK ❑ DOUNNACBrcY CI E STATE SITE PHOT WITH AREA CODE b DYv CA TYPE OF BUSINESS: [:] p DISTRIBUTOR ❑ 4 P ESSOR ✓Box if INDIAN EPA ID # /L IGAS STATION ❑ 1FARM 5OTHER TRUSTY ATION LANDS or ❑ �LGbO/� 686� AT THIS SITEVU EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) N CARE OFADDRESS INFORMATION �cJ MAIUN STREET ORES Box to Indicate 11 PARTNERSHIP ❑ STATE-AGENCY CORPORATION C LOCAL-AGENCY ClFEDERAL-AGENCY a `�Ady- INDIVIDUAL ❑ COUNTY-AGENCY CITY NA STATE ZIP CODE PHONE 4,WITH AREA CODE akAtl Cao 200 III. TAhi OWNER I ORMATION,& ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,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. ❑ ILLvIII.❑ 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 s JURISDICTION X AGENCY M FACILITY ID M R of TANKS N SITE 0 38 -) I 1010 1 o 101 CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT P'yo SUPERVISOR-OIs CT CODE BUSINESS PLAN FILED DATE FILED YES NO a4 CNEC PERMIT AMOUNT SURCHARG OUNT FEE CODE RECEIPT• BY: I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) - �x DATA PROCESSING COPY