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STATE OF CALIFORNS WATER RESOURCES CONTR OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r�:7 COMPLETE THIS FORM FOR EACH FACILITY/SITE C'4CIFORN�P MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE e I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I FACILITY/SITE NNAA/M�.E�D y� CARE OF ADDRESS NF/ORMMATIONN CARE OF ADDRESS INFORMATION n / / ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAIL or STREET ADDRESS / ✓ Box to indicate ❑ PARTNERSHIP El('�/ CORPORATION ❑ LOCAL -AGENCY ElSTATE-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY ADDRESS NEAREST CROSS STREET✓Boz indicate RPORATION El PARTNERSHIP ❑ STATE -AGENCY ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY W (►/'00 PH NE #, WITH AREA CODE 2 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME 7iel�c STATE ZIP CODE CENSUS TRACT 8 SLTE PHONE #, WITH AREA CODE BUSINESS PLAN FILED CA qS 7% Q3 °5 835=�lcla� TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID # [FILED d / CHECK # PERMIT AMOUNT AS STATION 3 FARM 5 OTHER ' [:]❑ RESELam TRUST LANI DS ON of ❑ /r C��i� BY: 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 7 X47/ NIGHTS: NAME (LAST, F ST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS NF/ORMMATIONN APPROVED BY NAME PHONE #WITH AREACODE n / / ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAIL or STREET ADDRESS / ✓ Box to indicate ❑ PARTNERSHIP El('�/ CORPORATION ❑ LOCAL -AGENCY ElSTATE-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY STATE CITY NAME Cc. STATE 71'��ICJ ZIP CODE PH NE #, WITH AREA CODE 2 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME . CARE OF ADDRESS INFORMATION APPROVED BY NAME PHONE #WITH AREACODE 4s MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY PERMIT NUMBER ❑ 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. ❑ 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 # AGENCY # FACILITY ID # 101 o z ;� 10 1 yj # of TANKS at SITE EmmvA CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE #WITH AREACODE 4s PERMIT NUMBER PERMIT APPROVAL DATE ER IT EXPIRATION DATE LOCATION CODE CENSUS TRACT 8 SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED DATE / Q3 � a �'0 1�� YES ❑ NO ❑ [FILED d / CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 8 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 FORM A (3-2-88) DATA PROCESSING COPY