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STATE OF CALIFORN10 WATER RESOURCES CONTR BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE = FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-11 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE W I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) m 00 FACILITY/SITE NAME i f- CARE OF ADD S INFO MATZO E_ V\ � - I0v Q lmm0�"b ADDRESS NEAREST CROSS STREET ✓Aox lo- iwa ❑ PARTNERSHIP ❑ STATEAGENCY POAATION ❑ LOCAL AGENCY ❑ EEGEAAL AGENCY ❑ INDIVIDUAL ❑ CAUNTYAGENCY CITU NAME I , �Y, STATE ZIP CODE ` SITE PHONE C:N.W-I ARq CODE TYPE OF BUSINESS'. ❑t,2 DDDII`ISST—'RIIBBBUTOR ❑ 4 PROCESSOR ✓BOx it INDIAN EPA ID k U (0 Gl,�l/ 9 RESERVATION or N of TANK'e ❑ I GAS STATION ❑ 3 FARM r 55OOTHER TRUST LANDS ❑ AT THIS SITEIn EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST.FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION dXj MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP C STATE-AGENCY C CORPORATION C LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL C 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 C( P'N_Q (Zo MAILING or STREET ADDRESS ✓Bax to intlicale ❑ PARTNERSHIP Cl STATE AGENCY C CORPORATION C LOCALAGENCYC FEDERAL-AGENCY C INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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. 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 k AGENCY R FACILITY ID 1t R of TANKS at SITE () o 1 FalaDl I O I o 10 (::) CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE It WITH AREA CODE E10 l f)V l ' - PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CQOE CENSUS TRACT SUPERVISOR- ST CODE BUSINESS PLAN FILED II NO/� VES NO C1 CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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(3-2-88) . DATA PROCESSING COPY