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STATE OF CALIFORNIX WATER RESOURCES CONTROZBOARD ,A FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE r FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEUTerf LOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME I\ � CARE OF ADDRESS INFORMATION ADDRESS C` f / NEAREST CROSS STREET ✓Bw to rAok ❑ P/AINDSwP ❑ STATE AGDRY 06 CORPOM70N 0 LOMAUNGY 0 FEDDYI-AGENCY 0 S ry ` n�O YI INDMWM 0 CWN -AGENC CITU NAME // STATE ZIP CODE / SITE ONE#,WITH AREA ODE K S 6 2V vU 3l TYPE OF BUSINESS 2 IBUIOR 4 PROCESSOR ✓Box it INDIAN EPA ID N B of TANK'A �l ❑ ❑ 5 OTHER RESERVATION or ❑ AT THIS SITE lJ ❑ 1 GAS STATION 3FARM ❑ 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 CRisr,Q . ,TeVe_ 2a — 5-34 NIGHTS'. NAME(LAST.FIRSTJ PHONE N WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION O LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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 ADDRBBB 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* JURISDICTION R AGENCY R FACILITY ID R M of TANKS at SITE ( d0007 CURRENT LOCAL AGENCY FACILITY 10( / ^ APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [CLHE N CODE CENSUS TRACT FZ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Z l 3 Z YES NO El 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�}J u\FORM A(3-2-88) / \,