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STATE OF CALIFORNIA WATER RESOURCES CONTROLOARD � � �:S.r -oF FORM `A': ym UNDERGROUND STORAGE TANK PROGRAM = SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH ACILITY/SITE C�NFORIP MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P NENTLY CLOSED SITE ► ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 ii I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME _ CARE OF ADDRESS INFORMATION ADDRESS �+� �� NEAREST CROSS STREET ✓BoxCO P indicate ❑ PARTNERSHIP ❑ STATE-AGENCY O /A/' A/1, 71 El CORPORATION ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY 'I (�(; I ❑ INDIVIDUAL ❑ COUNIY-AGENCY CITY NAME /� l STATE ZIP QDE SITE PHONE If,WITH AREA CODE 1v/ CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR -/Box if INDIAN EPA ID # #of TANK's ID 1 GAS STATION Ej 3 FARM ❑ 5 OTHER RESERTRUST LATIONANDS or El THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA COD DAY§: NAME(LAST,FIRST) /` PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PON #WITH AREA CODE NIGHTS: NAME(LAST,F ST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME ^ ,� CARE OF ADDRESS INFORMATION S" .JOA W!N 61AN7 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY r ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 1% ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE CJI PHONE#,WITH AREA CODE �llv 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME MO IQ ©U CARE OF ADDRESS INFORMATION SCo , I(c, -- MAILING or STREETESS ',�^y -/Box to indicate El PARTNERSHIP ElSTATE-AGENCY 4 I� 1 o Cl CORPORATION 1:1 LOCAL-AGENCY ElFEDERAL-AGENCY ` 'V ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME - STATE ZIP CPHONE#WI AREA ODE f-.q -4Zo S ��; BOr -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. ❑ if. ❑ 111.091 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 FPERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE F73P] I I I I I I I I 1010 1 1 101 0= AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 6'�I 6 > PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT# SUPERVISOR- �TRI,CTT CODE BUSINESS PLAN FILED DATE FI D (`I _'� 4 L/`0YES NO "PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY/:�i v— 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) 0 0 DATA PROCESSING COPY