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STATE OF CALIFORNIA' WATER RESOURCES CONTRbI040ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMs" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑,ANEW PERMIT F—] 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PER NTLY C EOSED SITE r ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W F+ FACILITY/SITE NAME CARE OF AD7RESS INFORMATION ADDRESS�IS 'l v W NA �OS� y ❑ R1RNEMP ❑ SrAllAGC k=011 ❑ LDMAG94M ❑ FEOFWAGENCY ❑ INDMDUAL D GGD147,40 NGY CIN NAMEc - /t STATCA ZIp.QF.;-01 SITE PHONE N. (CODE' TYPE OF BUSINESS: Thr', EPA ID p 4( S ' 2 DISTRIBUTOR 4 PROCESSOR ✓Roz it INDIAN RESERVATION or tt '' - Mol TANSY 0 ✓�1 GAS STATION ❑ 3 FARM ❑ S OTHER TRUST LANDS ❑ /V � AT 7X15 SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY - NAME(UST, IRST) PHONE If WITH AREA CODE DAYS: AME(LAST,FIRST) PHONE#WITH AREA CODE �(SI-�I sA s ,4 NIGHTS: AME(IAST,FIR ) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHON� ITH AREA CODE Y qA II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION olva MAILING or STREET ADDRESS ✓Box to inrlicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCALAGENCYD FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODEPHONE It,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME 5jA CARE OF ADDRESS INFORMATION MAILING o STREET ADDRESS ✓Sox to,nd,cate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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. ❑ III. ❑ 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 S JURISDICTION If AGENCY R FACILITY ID N V OI TANKS at SITE G 11 1= 1 cep 10 13 CURRENT LOCAL AGENCY FACILITY ID M APPR D B r F\ PHONE N WITH AREA CODE N 6.1 7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATTQN CODE CENSUS TRACT M SUPERVISOR-DIS ICT CODE BUSINES YPLAN❑FILEO NO / DAT FLED ES CHECK N C,1 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If IYJ�� L) S . 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) y DATA PROCESSING COPY �!'