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STATE OF CALIFORNII WATER RESOURCES CONTRROARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE I /� ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � COMPLETE THIS FORM FOR EACH FAC ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ AN Y CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT 1 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME TUT✓e( 0 01wt /!#(16ft4f, ARE OF ADDRESS INFORMATION ,SAAI 14 i , JOI E oe ADDRESS ^ � �� NEAREST CROSS STREET ✓COROitlnk D LOCAL IGEN D FEDERAL AGENCY ((� ❑ CORPORATION D COUNTY ❑ FEOEPAI AGENCY ❑ INOMWAI ❑ WONT/-AGENC! CITY NAME STATE ZIP COD ' SITE PHONE p,WITH AREA CODE CA S 2 TYPE OF BUSINESS: EPA ID # F-12 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box ifINDIAN ❑ If of TANK's i GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST TINLAND$oGI ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST, PHONE If WITH ARSA CQDE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE (f/Sf— 3 76 Y NIGHTS. NAME(LAST,F ST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME J n CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS /✓!VI ✓Box to indie.te ElPARTNERSHIP 13STATE-AGENCY 2 F ✓i 11 CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY l L F' F J D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME 1e STATE ZIP COD-2E � PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to inCicale 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADMIRES SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 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 R JURISDICTION R AGENCYIN FACILITY ID R S of TANKS at SITE " ® = 1010 0101011]_ CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE X WITH AREA CODE SAF PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE IC OCATION CODE CENSUS—i7pA -?j# SUPERVIS1 AIBT 1 ODE BUSINESS PLAN FILED DATE FILED 43 /i D dYES [] NOE] _ Z, i4f HECK# PERMIT AMOUNT SURCHARGEAMOUNIT FEE CODE RECEIPT# BY THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)01 MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.,5 FORMA(3-2-88)