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STATE OF CALIFORNIA` WATER RESOURCES CONTRUF BOARD FORM 'A': UNDERGROUND STORAGE TANK PROcARAM � o --SIT--E FACILITY/SITE, INFORMATION-and/oFP-ERMIT APPLICATION =' COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFC�Y ION ❑7 PER ANENTLY CLOSED SITE F"a ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITENAMECAREOFADDR INFO((pp•�MATION ADDRESSZNEAREST CROSS STR ftwolice# 11PAWNERSHP D STATE%NLY .R��'z- �j ra I1xJ2 l• 14 009CRATION ❑ LOCALJGOO ❑ KDOW.-MERCY ❑ RBrwx& ❑ WIMY-AGETICI CITY NAME STATE ZI SITE PHONE a,WITH AREA CODE o kfoti CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR -/Box if RESERVINDIAN or EPA ID a ❑ I GASSTATION ❑3 FARM 1 j h OTHER TRUST LANDS ❑ TMASSI - EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE llaoAes 131/ Zd? - - 1// NIGHTS: AME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE GIT' i/ 0?- /2 -.2/// II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION ME s MAILING or STREET ADDRESS ✓Box loindicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME J CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,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: 1. ❑ 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 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION B AGENCY R FACILITY ID# If of TANKS at SITE DE = = 10 10 -2i 1 Q I 10 10 CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE If WITH AREA CODE 1<��Y SU PERNIF NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED 2— O 2/7"? YES NO C] 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. / FORM A(3-2-88) �� FILE COPY �..