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STATE OF CALIFORN10 WATER RESOURCES CONTROARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE �'£'n"cuNery •TNF,, � N 1 1 'qC/pp p NSP MARK ONLY ❑ 1 N W PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION FACIIILITY IID # # of TANKS at SITE LkolI1116111 ' 1 U.S.4 ..enc, ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILING or STREET ADDRESS i^' /// Q y— ADDRESS ❑ INDIVIDUAL ❑ COUNTY -AGENCY NEAREST CROSS STREET ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CITY NAME .� Y) Fr` C < S C O De ❑ fOAPORATION 1:1 LOCAL -AGENCY ElFEDERAL-AGENCY PHONE #, WITH AREA CODE l �`99d - ?50 b e ,Leo A) IEl COUNTY-UNTY-AGENCY CI AME E ZIP CODE SITE PHONE #, WITH AREA CODE rEPA TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIANCA D # # of TANK's /GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or TRUST LANDS ❑Aplll� ] 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 T'A (� / J NIGHTS: NAME (LASTT,,FIRST) PH NE # ITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE EK II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME P,AetilroW CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION FACIIILITY IID # # of TANKS at SITE LkolI1116111 ' 1 U.S.4 ..enc, ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILING or STREET ADDRESS i^' /// Q y— ✓Vefxto indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CORPORATION 1-1LOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY l.� v ❑ INDIVIDUAL Cl COUNTY -AGENCY CITY NAME .� Y) Fr` C < S C O STATE /9(� ZIP CODE PHONE #, WITH AREA CODE l �`99d - ?50 b III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sa rn no ner FACIIILITY IID # # of TANKS at SITE LkolI1116111 ' 1 MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY AP VE BY NAME PHONE #WITH AREA CODE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, 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: I. X if. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY 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 0 Y. FORM A (3-2-88) 0_1 DATA PROCESSING COPY N 00 JURISDICTION # I 1 11 AGENCY # El I FACIIILITY IID # # of TANKS at SITE LkolI1116111 ' 1 GENCY FpACILIT�Yn`ID #Q�f L / U �L/ AP VE BY NAME PHONE #WITH AREA CODE [NUMBER PERMIT APjP)ROVAL DATE 11 PERMIT EXPIRATION DATE CENSUS TRACTT # fJl i U®IYES PERVISO -DISTRICT CODE BUSINESS PLAN FILED NO DATE FILED 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 0 Y. FORM A (3-2-88) 0_1 DATA PROCESSING COPY N 00