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STATE OF CALIFORNIA, WATER RESOURCES CONTROL ,AARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM m o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION O'a(If OPN1� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 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 I. FACILITY/SITE INFORMATION S ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION SKIPS SErEv« E ST rory _ ADDRESS NEAREST CROSS STREET ATE AGPICY CCFFCi 0 LOCI AGM 0 UFORK AGDXN joe s, LALIFOR/J/A 0 INDMDUAL 0 CUUMAGENa CITY NAME STATE ZIP CODE SITE PHONE 11.WITH AREA CODE 5`Tv�wratd CA C? TYPE OF BUSINESS2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID N _ N of TANK' ❑ ❑ RESERVATION or ❑ ❑ 1 GASSTATION ❑3 FARM 5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,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 M WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION PON40 iv4yoj 1.0 PTI-( MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY p 1-21ox (11 y4w1 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE /1{ooje�rsb GAP Y S III. TANK OWNER INFORMATION III ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to intlicate 0 PARTNERSHIP 0 STATE AGENCY 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITU NAME STATE ZIP CODE PHONE N,WITH AREA CCDE �rDAEsrb c/� 45357 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVIE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. 0 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION R AGENCY M FACILITY ID E •of TANKS at SITE " 3 o lr-> l ITO . 13 o a 10s CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE 0 WITH AREA CODE SKIPS 3a PER NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L CATION CODE CENSUS TRACT• SUPERVISOR-DIST111CT CODE BUSINESS PLAN FILED DATEFIYE8 NO (! S /ECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY:10._r 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)