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_..._ ._.- r _.. ._T ;r7{-, +r.�.►.---v-7.-'.>e.1-.-,�..-w-�-�+..+.r-ver•...-..�+l��7!'+t1�Tr..-rws-�..r'�S�"�.rmr..yRv.•,..r..4.n rn�SF'•t*+r�•r�.T.....�.grnr�+r-..,.-•. � Y �1- STATE OF CALIFORNIA* WATER RESOURCES CONTRO ARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ' uo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 —� COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ I NEW PERMIT n 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE f' ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE cm I. FACILITY/SITE INFORMATION &AD ESS—(MUST BE COMPLETED) N FACILI /SITE NAME ` CARE OF ADDRESS INFORMATION _ �6k f"3f/dllerrplA0 ADDRESSNFAREST CROSS STREET ✓8a 14 r&* EIPARYWalP EISTATE•AGENLY lJ aZ �_ __ G, `� (7Wr ❑ WMD Al ❑ OO.RM-AGENCY CITY NAME G STATEP CODE SITE PHONE N,WITH AREA CODE 5 Cx D,�1 CA YS':Z x TYPE OF BUSINESS. ❑ ISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N N oI TANK's RESER❑ ❑ TRUSTVLANDS ATION or ❑ I GASSTATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME([AST,FIRST) PHONE N WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Dox to Inoicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FFOERAI.-AGFNCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE 7Trl WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to oftale ❑ PARTNERSHIP ❑ STATE-AGFNCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. if. n III.❑ THIS FORM NAS DEEN COMPLETED UNDER PENALTY OF PERJURY,ANO iO TIIE(TEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N N u1 TANKS s1 SITE El El I z/ �_ _ 0 0111 CURRENT LOCAL A E Y A ILI / _T APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED 23, 2YES ❑ NO ❑ S" /' CHECK N 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) 7� DATA PROCESSING COPY