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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD a. 5E f f � 1 tu..xx FORM A: UNDERGROUND STORAGE TANK PROGRAM io Z SITE Gr FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o l 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE ------ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA CLOSED SITE (--► ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE r I 4 I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N FACILITY/SITE NAME 1 CARE OF ADDRESS INFORMATION Ar L Cres ADDRESS / NEAREST CROSS STREET Bm dmPN ;IP ❑ STATE AGENCY AP, O W ✓ ¶GLOCAL AGENCY ❑ FEDEML AGENCY 11 ❑NONODUNTY-AGENCY ❑ CITY NAME _ _ / STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE O USINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR I '/Box if INDIAN EPA ID # 1 GAS STATION ❑ 3 FARM ❑5 OTHER RESERVATION or ❑ - #of TAHK'N TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) rk PHONE#WITH AREA CODE DAYS. NAME(yy^^ST,FIRST) PHONE WITH AREA CODE 59- AfJcl�-t, utF,(, � Gne2 — IIf7 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LA ,FIRST) PHONE#WITH AREA CODE ( ( v1 II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME k / CARE OF ADDRESS INFORMATION v t.. MAILING or STREET ADDRESS ✓Box to indicate 1:1 PARTNERSHIP STATE-AGENCY ZO At ( o ,5:4 El� El NONIORATION 13 ElLO ALNAGENCY AGE CY 11FEDERAL-AGENCY CITY NAME / STATE_ ZIP CODE / PHONE 41,WITH AREA CODE N /V• � S III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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: I. 10n IL ❑ 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# #of TANKS at SITE ® Z= lJ 0 CURRENT LOCAL AGENCY FACILITY I/D'N' APPROVED BY NAME PHONE N WITH AREA CODE vv PERMIT NUMBER IINERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ird YES [:] NO [] 3— 6 i CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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) III'gl/// • DATA PROCESSING COPY •