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STATE OF CALIFORNIA WATER RESOURCES CONTROL toARD FORM A: UNDERGROUND STORAGE TANK PROGRAMo Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o COMPLETE THIS FORM FOR EACH FACILITY/SITE "" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE IJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 15 W I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N W FACILITY/SI NAME CARE OF ADDRESS INFORMATION E- YE 1 u-- ADDRESS NEAREST CROSS STREET iicle ❑ PARTNERSHIP ❑ STATE-AGENCY ✓a ,d4110N ❑ LOCALAGENCY ❑ FEDERALAGNC Y Wliko C D INOMDUAL D COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE Fb co-Lay-A, CA aog l63 1I 1p� TYPE OF BUSINESS: [v�r2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID If k of TANK's //�� ❑ 1 GAS STATION 3 FARM ❑ RESERVATION or ❑ AT THIS SITE Ob 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME ,FIRST) PHONE 4 WITH AREA CODE NIGHTS. NAME(LAST,FI PHONE 4 AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION R6L m AD RESS MAILING or STREET ✓BY.to indicate Cl PARTNERSHIP Cl STATEAGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY S I 1 LC .P–IOIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ^^ ^^ CARE OF ADDRESS NFORMATI ON l.la� MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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 as COUNTY k JURISDICTION k AGENCY k FACILITY ID k At of TANKS at SITE b 10 11 qF0 I ol 0 1 CURRENT LOCAL AGENCY FACILITY IO k ^K I En ,�— APPROVED SY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CGDE CEN STRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED (� p /LhJ aTj,, VES NO [:] i L l� CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: 1 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. \vA-JI FORM A(3-2-BB) • DATA PROCESSING COPY