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STATE OF C/ALIIFOR WATER RESOURCES CONTAUeBOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �1m" o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT E]3 RENEWAL PERMIT CHANGE OF INFORMATION F-17 PERMANENTLY CLOSED SITE ONE ITEC! ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE CO 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) I" t77 FACILITY/SITE NAME ( )unlF?)/ LV(J v(Cf-' CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓y➢A�.b f ele ❑ PARNEM10 ❑ STATEAGENCY LVD CONPOMTION ❑ EOCk-AGENCY ❑ FEDEMA(,TNCY (►J ❑ INDIVIDUAL ❑ tX1UMTY•AGENCY CITY NAME STATE ZIP CODE SITE P NE N,WITH AREA CODE CA ZU Cl3-o TYPE USINESS: 2 DISTRIBUTOR 4 SSOR ✓Box if INDIAN EPA ID N RESERVATION or N of TANK>< AS STATION 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE Q4 3-o+ ows " .11 LL_ q1 (p) 031- 16AI NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 5 -53 5Z o ql 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION t� 1!. �I L.1._ N O Ll.1S MAILING or STREET ADD ESSV Ilr .)T�O ✓JQMTo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 8 ) ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAT ZIP CODE P ONE N WITH AREA CODE A ) 0lv3 - 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION L ( MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY D `� \I(J CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY E �^1 STAT ZIP CODE PHONE N,WITH AREA CODE lJ` j IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR 13OTN LEGAL NOTIFICATION AND BILLING: 1. 11. ❑ Itl. 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE ® I I I I LLI i I g 1 14-1 L I I J�fl_ CURRENT LOCAL AGENCY FACT IDN APPROV D BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE r' LOCATI CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D a3 gO IL YES NO 0 8 CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ON ./ FORM A(3-2-98) ter.. �/ DATA PROCESSING COPY ��