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r � STATE OF CALIFORN& WATER RESOURCES CONTRBOAiID FORM'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C/ COMPLETE THIS FORM FOR EACH ACILITY/SITE--= MARK ONLY 1-11 NEW PERMIT ❑ 3 RENEWAL PERMIT P15 CHANGE OF INFORMATION ❑ 7 PL"NENTLY CLOSED SITE ONE ITEM El INTERIM PERMIT El4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C f 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITENA - (41AV Wt_gferri CARE OF ADDRESS INFORMATION ADDRESS / /1 �_I ` W ✓ x Io indicele ❑ PARTNERSHIP ORPORATION ❑ LOCAL -AGENCY NEAREST CROSS STREETIO WIElP/ATNRSHP ❑ STATE AGENCY Wf9ORAPON 13LOCA AGENCY FEDERAL -AGENCY ❑ INgNWAI ❑ WUNtt#(KN'IX CITY NAME INDIVIDUAL D COUNTY -AGENCY STATE ZIP CODE SITE PHONE#, WITH AREA CODE S2o S Za - L/6 0 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 1 GAS STATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER ✓ Box if INDIAN TRUSESETYATION LANDS or ❑ -CA EPA ID # of TANK's AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) PERMIT AMOUNT EMERGENCY CONTACT PERSON (SECONDARY) DAYS'. Vj (LAST, FIRST)ONE DEKZ� # WITH AREA CODE FpmPH?,6l—q4l-# DAYS: NAME (LAST, FIRST) PHONE R WITH AREA CODE 0 o 26 ——d 0 NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # ITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMEn--O JIV I CARE OF ADDRESS INFORMATION MAILING or STREET ADDR SSox MAILING or STR ADaDRESS� / (7(• ✓ x Io indicele ❑ PARTNERSHIP ORPORATION ❑ LOCAL -AGENCY ❑ STATE -AGENCY ❑ FEDERAL -AGENCY O CORPLaOflATION D LOCAL -AGENCY D FEDERAL -AGENCY INDIVIDUAL D COUNTY -AGENCY CITY NAMEF MPGR V F��r CITY NAME STAT ZIP I? We'/ PHONE p, WITH AREA CODE 611<1_� 111. TANK OWNER INFORMATIOd & ADDRESS — (MUST BE COMPLETED) NAME P/0 CARE OF AD SS INFORMATION MAILING or STREET ADDR SSox CURRENT LOCAL AGENCY FACILITY ID N STARS 9 ift.te D PARTNERSHIP D STATE -AGENCY APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER CORPLaOflATION D LOCAL -AGENCY D FEDERAL -AGENCY PERMIT APPROVAL DATE INDIVIDUAL D COUNTY -AGENCY CITY NAME LOCATION CODE Q STATE ZIP CODE PHONE#. WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS z CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # ®== JURISDICTION X AGENCY R FACILITY ID If B of TANKS N SITE 011oaz CURRENT LOCAL AGENCY FACILITY ID N STARS 9 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE Q CENSUS TRACT # gQ SUPERVISOR -D TRICT CODE ;j7 BUSINESS PLAN FILED YES � NO ❑ DATE FILED x.17, CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM 'B' APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A (3-2-8S) DATA PROCESSING COPY 'Nsm" of