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STATE OF CALIFORNIV WATER RESOURCES CONTROWARD FORM A'; UNDERGROUND STORAGE TANK PROGRAM �a SIT5 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION (_11 COMPLETE THIS FORM FOR EACH FACILITY/SITE �a(,FORN\P MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMITEj�-<CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED)s FACILITY/SITE NAME _ IR Hemor j gap, CARE OF ADDRESS INFORMATION 1)I R I 1 b ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ADDRESS ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY NEAREST CROSS STREET -w/ B ate C3 PARTNERSHIP ❑ STATE -AGENCY Y—�IGN ❑EEDERAL-AGENC TO V NDIVIDUALE3COUNTY-AGENCY CITY NAME 1 � � ❑ INDIVIDUAL ❑ COUNTY -AGENCY STATE CA ZIPCODE 5 37 iv SITE PHONE #, WITH AREA CODE 2 0'v'3_5-)'500 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PRO SSOR ✓Box if INDIAN RESERVATION or EPA ID # * 1 # of T1�111C'a 1 GAS STATION 3 FARM OTHER ❑ ❑ ��-�sav TRUST LANDS ❑ 1vdN� AT THIS SITE 4 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE � �'?) -lSoc 1 -lcr r� C l a l.�c (e i b'35 -1SDO NIGHTS: NAME (46AT, RST) PHONE#'WITH AREA CODE NIGHTS: NAME (LAST, IRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME -TQ V Mu(v I CARE OF ADDRESS INFORMATION b I Lb ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ✓ Bprto indicate ❑ PART RSHIP ❑ STATE -AGENCY CITY NAME Tj� ^ O / l n kKtT [a"CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY «l 1 1—R ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME 1 STATE ZIP CODE PHONE #, WITH AREA CODE PERMIT APPROVAL DATE C A s3 Co ��-�sav III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY # of TANKS at SITE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY I I I I ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS i I CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. E�j' It. ❑ III. ❑ I 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 # # of TANKS at SITE 3 GI I I I I EI I I I O I O I I I q I 3� p I -T-41_ O CURRENT LOCAL AGENCY FACILITY I # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED DATE FILED 6 � d- -3 �� YES ❑ NO ❑ �— Z-W 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 ON RM A (3-2-88) DATA PROCESSING COPY N w