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STATE OF CALIFORN►_ WATER RESOURCES CONTRA ,c. BOARD FORM'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE SxP� o�FM1 ` e , Z .. 10 C9lIFOpN�P MARK ONLY Q1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE 61 1 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/BETE NAME CARE OF ADDRESS INFORMATION t as CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to iWicate' 0 PARTNERSHIP 0 STATE -AGENCY o A clers 6o%n+ eu D INDIVIDUAL D COUNTY -AGENCY ADDRESS STATE ZIP CODE NEAREST CROSS STREET oncim 0 PA ENBIIP D STATE AGEND CENSUS TRACT N 3 D SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES � NO DATE R D7RgMTIGN D LOGL-A M D RMEWI-MEHCY F1U W FlEE CODE D INDVIIXW D CQAIY.AGENCf CIN NAME BY: STATE ZIP CODE SITE PHONE N, WITH AREA CODE N CA 615--238"7 TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑ 4PROCESSOR ✓Box it INDIAN EPA ID N 1 GAS STATION 3 FARM ❑ ❑ 5 OTHER RESERVA❑ or TRUST LANos ❑, AT THON AISHSITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST)PHONE N WITH AREA CODE DAY . NAM (LAST, FIRST) PHONE N WIT PEA CODE wJ'l66�Y g O = rl NIGHTS: 14AME (LAST, FIRST) PHONE N WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE,N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) I l r''ff NAME CARE OF ADDRESS INFORMATION t as FACILITY ID N N of TANKS at SITE 4� 10o . MAILING or STREET ADDRESS ✓ Box to iWicate' 0 PARTNERSHIP 0 STATE -AGENCY APPROVED BY NAME PHONE N WITH AREA CODE 0 CORPORATION 0 LOCAL -AGENCY ❑ FEDERAL -AGENCY D INDIVIDUAL D COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE N, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION e QS FACILITY ID N N of TANKS at SITE 4� 10o . MAILING or STREET ADDRESS ✓ Box to irkicete ❑ PARTNERSHIP 0 STATE -AGENCY APPROVED BY NAME PHONE N WITH AREA CODE ❑ CORPORATION ❑ LOCAL -AGENCY D FEDERAL -AGENCY 0 INDIVIDUAL 0 COUNT'( -AGENCY CITY NAME STATE ZIP CODE PHONE N, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS v� CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1.9 11, ❑ 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 M JURISDICTION R AGENCY N FACILITY ID N N of TANKS at SITE 4� 10o . CURRENT LOCAL AGENCY FACILITY ID N cmr 3 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT RO AL DATE PERMIT EXPIRATION DATE CATION CODE [COHE CENSUS TRACT N 3 D SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES � NO DATE R CKN PERMIT AMOUNT SURCHARGE AMOUNT FlEE 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) DATA PROCESSING COPY �1J; cn OD