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STATE OF CALIFORNI^ WATER RESOURCES CONTR0-VBOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM 'moo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m ' r� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PER Y CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT El 4 AMENDED PERMIT E16 TEMPORARY SITE CLOSURE I. FACILITY/SITE IINFORM/ATION &ADDRESS/— (MUST BE COMPLETED) FACILITY/SITE NAMI�T/ ✓'�� ,� .(\ CARE OF ADDRESS INFORMATION ADDRESS / NEAREST CROSS STREET ✓Box to njc* ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ WWWTION ❑ LOCAL KOO ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY.AGENC( CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE M'c CA 6 .O TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N RESERVATION or Mol HIS SITE 1 GAS STATION [-] 3 FARM ❑ 5 OTHER TRUST LANDS ElAT THIS STE v EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS, NAME(LAST.FIRST) PHONE N WITH AREA CODE Ao 6 2 —3 'O? NIGHTS: NAME(LAST,)FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE M WITH AREA CODE II. PROPERTY 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 N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION Cl 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)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 M JURISDICTION 0 AGENCY01 FACILITY ID N 0 of TANKS•1 SITE = &_�lo0G CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE•WITH AREA CODE 7L A' // Y J PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT COOK BUSINESS PLAN FILED DATE FILED 1-3 j Z-6 YES ❑ NO %_ CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ONLY. FORM A(3-2-88)