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STATE FA % L. LIF©RNIA (NATER RESOURCES CONTROARD �;. ... FORM `A': UNDERGROUND STORAGE TANK PROGRAM h � SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Icy COMPLETE THIS FORM FOR EACH FACILITY/SITE "=-+PORN% MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM Fe2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �a I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION OiLSE)"- 0127ry ADDRESS y/s �^'� NEAREST CROSS STREET ✓B 'nd�cePe ❑ PARTNERSHIP ❑ STATE-AGENCY � ��_ _ f D p''- cz �r ' nprvI� Qi* NDIVOLIALCORPORATIGy 0 LOCAL-AGENCY❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY CITY NAME c� STATE ZIP CODE SITE PHONE N.WITH AREA CODE v 0 CA d, a q? 'f6 3-/�9 TYPE OF BUSINESS, ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box If INDIAN EPA lD 4 ❑ TRUST VATION LANDS Q ❑ I a tv C #of TANK'HIS SI +—� 1 GAS STATION 3 FARM 5 OTHER AT THIS 517E `-JS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS �✓B ,to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY el? 4 /,forty , Or f.�� , I.5 L—CORPORATION ❑ LOCAL-AGENCY C] FEDERAL-AGENCY of f 6 �(j�(J Q INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE _ PHONE#,WITH AREA CODE a `f` ' re e,k CIS 1 9'gD9(�o I 15 `f 6 7 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ,I�omom_rtuowaer MAILING tar STREET ADDRESSCT v v ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 0,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. El III Ill. ❑ 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 FPERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE [M I I El I I lolol1l1lKL11 fyAGENCY FACILITY ID# APP YED BY NAME PHONE#WITH AREA CODE ti PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT# SU ERV/.ISSOR-DI TRICT CODE BUSINESS PLAN FILED DATE FILEDD RO ( YES NO 17 t CHECK# 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. r�elaM A(sz-asf ,�\J 0 DATA PROCESSING COPY 0