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STATE OF CALIFORNS WATER RESOURCES CONTROBOARD FORM 'A': A UNDERGROUND STORAGE TANK PROGRAM � m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z 10 COMPLETE THIS FORM FOR EACH F CILITY/SITE R FMARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERM AN N LOSED SITE F+ ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N C�,JA.�I FACILITY/SITE NAME CARE OF ADDRESS INFORMATION V Froe- 1Ih looI r ADDRESS NEAREST CROSS STREET ✓&I to wil.le ❑ PAPTNENGHIF ❑ STATE AGENCY CORPOR 103 CITY NAME ' ❑ INDIVIDUALKTION Cl COUNTY L ENC AGENCY ❑ FEDEMLAGENCY OS S ATE ZI CODE SITE PHONE I.W TH AREA CODE L CA TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓ ❑ Box if INDIAN EPA ID a ❑ 1 GAB STATION ❑ 3 FARM �,rQ(HER TRUSRESET ATION or ❑ - /T� 6 _ AT THISMs � �"��"� ATTNISKs It EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE r Caoq �F NIGHTS: NAME(LAST,H T PHONE ft WITH AREA CODE NIGHTS: NAME)LAST.FIRST) PHONE 0 WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box m intlicale 13 PARTNERSHIP IDSTATE-AGENCY El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCYCITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME S± - CARE OF ADDRESS INFORMATION ro e l� , e� MAILING or STREET ADDRESS ✓Sox to indicate 11PARTNERSHIP Cl STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZI ODE PHONE4WI.H AREA CODE L/ a0 /7� IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ 111. ❑ 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 R JURISDICTION R AGENCY k FACILITY ID M B of TANKS at SITE In 06d 1 CURRE T OCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE If WITH AREA CODE ZNUMBER ( o PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED > pl, YES NO �l IS- CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BOY:' /// 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) 40 4p DATA PROCESSING COPY