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STATE OF CALIFORNIAs WATER RESOURCES CONTROLb4ARD FORM A: UNDERGROUND STORAGE TANK PROGRAM mo Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1O COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 NTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) O FACILITY/SITE NAME SlArrIP,161CARE OF ADDRESS INFORMATION tp 6k_ p'j M A/N"/114MANbk 1 NEAREST CROSS STREET ✓Bm kwose 0 PARTNERSHIP STATERGENCY ADDRESS 1 ( �1� kA W Cl INNIWMk 0 l�ry G RGEPPL AGENCY CITY NAME o N1 CY STATE 21P CO E SITE PHONE X,WITH AREA CODE s1 "7oJt CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑1 ESSOR ✓Box if INDIAN EPA ID X If at TANK's F-1I GAS STATION F-13 FARM S OTHER TRUSTYATION LANDSo ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME ST,FIRST) PHQNE M WITH AREA CODE NIGHTS'. NAME(LAST,FI PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRS PHONE X WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION I MAILING or STREET ADDS 5 ✓Box To intlicale ❑ PARTNERSHIP 11STATE-AGENCY I G , Cfftl//J ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY (/ ` y/T/ ❑ INDIVIDUAL ❑ COUNN-AGENCY CITY NAME STATE ZIP CODEPHONEN,WITH AREA CODE 5-rv— 8 d Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION A 5 MAILING or STREET ADDRESS ✓Box W M,cale Cl PARTNERSHIP 0 STATE-AGENCY Cl CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 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. I. El 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY X JURISDICTION X AGENCY# FACILITY ID X X of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDX APPROVED BY NAME PHONE N WITH AREA CODE /w- PERMIT NUMBER PERMIT APP OVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / 23 cl d Zd YES NO � �j—/ 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. FORM A(5-2-88) ) baa DATA PROCESSING COPY "�