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STATE OF CALIFORN►., WATER RESOURCES CONTROL BOARD / .... ' FORM 'A': SITEUNDERGROUND STORAGE TANK PROGRAM �CILITY/SITE, INFORMATION and/ r PERMIT APPLICATION �/ COMPLETE THIS FORM FOR EAC)l FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT rj 5 CHANGE OF INFORMATION ONE ITEM F-1 2 INTERIM PERMITElT PERMANENTLY CLOSED SIT N ❑4 AMENDED PERMIT ❑8 TEMPORARY SITE CLOSURE qq � I.FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) / [ADPDRESS TY/SITE NAME 5c CARE OF ADDRESS INFORMATION Gt/n `-�G� NEAREST CROSS STREET ✓3mro a pMTNE3341p STALE AGENp��{ GC . ❑ COKPATION ❑ LOGL-AGRiLY� 0 FEOERLAGDCYAME 0 INDIVIOUAL 0 WUNTYAG90STATE ZIP CODE SITE PHONE N,WITH AREA CODEICA C Log �S 9 1 i 3iF BUSINESS: 2 DISTRIBUTOR ❑4 A ✓Box if INDIAN EPA ID pGAS3TATION ❑3 FARM OTHER RESERVATIONTRUSTLANDS or ❑ #aITANM# 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#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION r /o Gly!eflPC �CKpJ� MAILING or SIRE ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY G ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 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. ❑ ILL❑ 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 9 1 0 1 0 1 a 1 s Y 3 1 D 1 C2C3 3 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE 2/ OCL/ 30 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED QS �? 3,5-D 3-D4 I YES [-] NO [] a/4/ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: CD A THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FO A(3-2-58) •_ DATA PROCESSING COPY v f