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. .,,jam,,,..Re.sy. ..,...a, .T..ca • x STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '"`"""` ` o-�;r, .' FORM `A': UNDERGROUND STORAGE TANK PROGRAM _ o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE - ""�"-=�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 P Y CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 10 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME fl CARE OF ADDRESS INFORMATION ADDRESS q }� NEAREST CROSS STREET abide ❑ PAIQNESSHP 11 STA" N V / SNSNDMDGAI N ❑ CO"'AGENCf ❑ FEGER44AGENLY CITY NAME ,/ STATE ZIP CODE SITE APHONE N,WITH AREA CODE TYPE OF BUSINESS: ❑ 2DISTRIBUTOR / ESSOR ✓%Box if INDIAN EPA ID # 9 AF TANK 1 GAB STATION 3 FARM 5 OTHER 's RESERVATION or AT THIS SITE I ❑ TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAM (ITAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE IVjLp/O�Sor MA ?A P 2 V dK NIGHTS: NAME(LAST.FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE Ell N I1. PROPERTY OWNER INFORMATION &ADDRESS --(M ST BE COMPLETED) NAME ` ^ IEN / O cl ?90 C�A�� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS l{�U on to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 1 0 n T CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY M1 J ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMESTATE ZIP CODES / PHONE N,WITH AREA CODE �7e 111. TANK OWNER INFORMATION &ADDRESS -(MUST BE COMPLETED) NAME ^ � CARE OF ADDRESS INFORMATION E/Lr# MAILING or STREET ADDRESS B to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY A ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 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: L ❑ it. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION K AGENCY* FACILITY ID# #o/TANKS a1 SITE = I b0 0 / �0 CURRENT LOCALAO CY FACILITY N APPROVED BY NAME PHONE K WITH AREA CODE /LL1/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [LOCATIONM CODE CENSUS TRACT# SUPERV -DISTRICT CODE BUSINESS PLAN FILED�TQ wElYES NOO CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE 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. �VA )FORM A(3-2-88) DATA PROCESSING COPY �