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STATE OF CALIFORNIWATER RESOURCES FORM `A': CONTROL BOARD SITE UNDERGROUND STORAGE TANK PROGRAM A FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE n FMARK ONLY ❑ I NEWPERMIT ONE ITEM ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑2 INTERIM PERMIT q AMENDED PERMIT ❑ PERMANENTLY CLOSED SITE N 11 L FACILITY/SITE INFORMATION & ADDRESS — S TEMPoagayslTECLosuRE FACILITYrSITE NAME (MUST BE COMPLETED) V S' P� S CARE GFADDRESS INFORMATION cc ADDRESS Ndl,tc �yyy C NEAREST CROSS STREET ✓Boa.lo iN¢ale CITY NAME rI S / ❑ PAFAt AGENCY ❑ STATE S1 / / C ❑ INDIVIDUAL CORPORATION D lOCA6AAGENC ❑ FEDERAL /GCKT�� STATE D COONtt�AGENLY ZIP ODE SITE PHONE N,WITH AREA CODE ❑Tl l GA STATI N: ❑p DISTRIBUTOR ❑q PROCESSOR ✓Box it INDIAN EPA D NA >��^ 4 I GAS STATION ❑3 FARM OTHER RESERVATION or EMERGENCY CONTACT PERSON(PRIMARY) TRUSTLANDS ❑ If of TANK's AT THIS SITE Y DAYS: NAME(LasT FIRST) EMERGENCY CONTACT PERSON(SECONDARY) 1 PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) O N(� k, ? PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) Lw"4- LP PHONE N WITH AREA CODE NIGHTS: NAME(LAST FIRST) 3/2 PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS NAME (MU— ST BE COMPLETED) brinkP /�_ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS %/ £N LeP 'I 55 S okie p_ ✓Box to intlicate ❑ PARTNERSHIP CITY NAME SUr f[.S$f /XN 12&� CORPORATION ❑ LOCALAGENCYSTATE-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY FEDERAL-AGENCY STATE ZIP CODE Ti PHONE I.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED NAME PYIe CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ CORPORATION E3LOCAL-AGENCYEl El STATE-AGENCY CITY NAME ❑ INOIVIDUAL ❑ COUNTY-gGENCV FEDERAL-AGENCY 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID If saaaas #Of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE 6N/ PERMIT NUMBERPPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS LOCATION PERMIT A T N pp SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED p� DATE FILED CHECK N PERMIT AMOUNT ✓EAS YES NO SURCHARGE AMOUNT FEE CODE / fJ flECE1PTM BY: THIS FORM MUST BE ACCOMPANIED BY AT LE(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SyyNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.^ FORM A(3-2-88) —� DATA PROCESSING COPY _ \U