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STATE OF CALIFORNIA WATER RESOURCES CONTROL _JARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE 4: - Y`n 0 I/ I C�[IFOF��P. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION ;nvi.ron,r_ental C(mpliance Sectiou MAILING or STREET ADDRESS ADDRESS NEAREST CROSS STREET ✓ Boz to Indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CITY NAME STATE ZIP CODE ''CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY CENSUS TRACT # SUPERVISOR -DISTRICT CODE X415 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME PERMIT AMOUNT STATE ZIP CODE RECEIPT At SITE PHONE If, WITH AREA CODE CA TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID N If of TANK's ❑'1 GAS STATION 1:13 FARM El OTHER RESERVATION or TRUST LANDS [:] AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS. NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE (209) 83.5-7777 ARCO Maintenance ,415 NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE It WITH AREA CODE C' '.00 431-9Z! II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION AGENCY # 1 1= Ll ;nvi.ron,r_ental C(mpliance Sectiou MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY PERMIT NUMBER ❑ INDIVIDUAL Cl COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE N, WITH AREA CODE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE X415 I11. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION AGENCY # 1 1= Ll Environmental Compliance Section MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY .fl CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY PERMIT NUMBER ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT 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 Frances W. Hedrick A, t for ARCO TT7<frv47 rvm ■ rd 3a\ t 1 w COUNTY # m JURISDICTION # I 1 1-1 AGENCY # 1 1= Ll FACILITY ID # F -TI 1-1 # of TANKS at SITE LLI I I CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO ❑ DATE FILED CHECK # L. PERMIT AMOUNT SURCHARGE AMOUNT _]__FEE CODE RECEIPT At 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 INIFUHMAf IUN UNLT, FORM A (3-2-88) LOCAL AGENCY COPY