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STATE OF CALIFORNI WATER RESOURCES CONTRO.OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMsit SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '° COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT F13 RENEWAL PERMIT El]-5-'CHANGE OF INFORMATION ❑ 7 PERMAN NT;LY CLOSED SITE ONE ITEM El INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �f I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACt ITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BwIDr&* ❑ PARTNI&V ❑ STATE AGENCY Cl COW&TOi ❑ LOCAL AGENCY ❑ FEDFAAL AGENCY O �. /�7Q/h ❑ NIDIvw& ❑ CDUNTY-AGENCY CITY NAME F STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA y5-Cp_ 20%— 5'1/,f— _301/45 TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box If INDIAN EPA ID N 1 (� RESERVATION or ❑ 0l TANK'S , I AS STATION L J 3 FARM L HER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAPS NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAIL ING oI STREET ADDRESS ✓Box to Indicale ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE M.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY — ❑ INDIVIDUAL ElPHONECITY NAME STATE ZIP CODE PHONE M.WITH AREA CODE lC 01— IV. LIV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(11 BOX INDICATING WHICH ABOVE ADORE"SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ JHIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPt ICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY ECHIECK JURISDICTION N AGENCY N FACILITY ID k / N of TANKS at SITE [11_1 T L L I - T= AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 off— UYES ❑ NOPERMIT 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 ONLY. FGHM A,J Da) C