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STATE OF CALIFORNIIF WATER RESOURCES CONTROL =F FORM `A': UNDERGROUND STORAGE TANK PROGRAM ;" a SIT� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION °< o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ T NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I"a ONE ITEM ❑ 2 1NITERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE J V W O I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ~ 07 FACILITY/SIT AME CARE OF ADDRESS INFORMATION even I'V\ euirle_ ADDRESS NEAREST CROSS STREET ✓R0,I0,rd.le ❑ PARTNERSHIP ❑ STATE AGENCY S I nJ l 1 n I ❑�1BPORATION ❑ LOCAL AGENCY ❑ FEDERAL NT $INUIVIUUAL ❑ COUNTY-AGFNCY CITY NAME STATE ZIP C DE SITE PHONE N,WITH AREA CODE n ca CA 5 33 Z og $SS( z TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ROx if IN EPA ID # RESERVATION or -,�,�— #of TANK'# ❑ 1 GASSTATION ❑ 3 FARM OTHER TRUST LANDS AT THIS SITE oil EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA�ST,FN) ` 'I n PHONE#WITH AR A C� DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME OUST,FIRST C•V •K PHHOO`/NNE`I#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION "gy m O P u) r)/_ T) I'Y'L Oe U it nem MAILING or STREETADDRESS ✓Box to indicate 13 PARTNERSHIP ElSTATE-AGENCY 1 I S , El CORPORATION ❑ LOCAL-AGENCY 1:1 FEDERAL-AGENCY 1 , t • 1 (L 61,191LIVIDUAL ❑ COUNTY-AGENCY CITY NAME i. STA ZIP CODE PHONO,WITH AREA CODE G rt I ccs IRSrLF 9 S III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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. ❑ if. �11I. ❑ 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 ® 100 CURRENT LOCAL A�G)ENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE VI� I � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE YFORMA(3-2-88) CODE CENSUS TRACT CTT# SUPERVISOR-DIS T RICT CODE BUSINESS PLAN FILED DATE FILED. C' Z3YES ❑ NOPERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION DATA PROCESSING COPY