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:.. � �r,•�•�-SFA-..,.� STATE OF CALIFORNIP WATER RESOURCES CONTRONOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM =`° o SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM AEN;;*^'OSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ��3 ` I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N OD FACILI ITE NAME CARE OF PAPDRESS INFORMATION �i�y(C 0 ADDRESS�T /� �7f/� N AREST CROSS STREET ✓ilrOr mute O PARTNENSNIP ❑ STATE AGENCY D (.-S �' W✓/" / ! - ,^ _ ❑ CORPORATION C LOCI-AGENCY FEDERAIA CY ❑ INOrvIDUAL ElCWNttAGENCY CIN NAM!^'16 STATE ZIP.Q7 SITE PH NE WIT AREA CODE CA I 2, s' ��'U -Gv � s TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR I ✓Box if INDIAN EPA ID # RESERVATION or �1 #of TANK's /� ❑ 1 GASSTATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ ILIIA AT THIS SITE D(/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS eN ST,FIRST) PHONE WITH AREA GOOE OAVS. NA E(LAST FIRST) PHONE pyJITH AREA CODE NIGHTS: NAME ^ST.FIRST) r^� � NE p6THIIA6R�✓A1J CCOODE NIGHTS`j�NAME(LAST,FIRST) PHONES jYWITH AREA CODE 14 II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) )"/ NAME CARE OF ADDRESS INFORMATION MAILING or STA ET AD ESS I/BIG.to indicate C PARTNERSHIP C STATEAGENCY IllCORPORATION C LOCALAGENCYC FEDERALAGENCY S A C INDIVIDUAL C COUNTY-AGENCY li CITY NAME/0 STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP C STATE-AGENCY ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. v if. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE = = oa 3 6 101610101 CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME I PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR- STRICT CODE BUSINESS PLAN FILED DATE FILED C ' $ b YES NO �rli CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Al 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 FORMA(3-2-88) J DATA PROCESSING COPY 0