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STATE OF CAL I FO R N IR WATER RESOURCES CONTABOARD r Eh f OF T"F FORM `A': UNDERGROUND STORAGE TANK PROGRAM o S T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z , COMPLETE THIS FORM FOR EACH FACILITY/SITE �gc,FOR�'P MARK ONLY ❑ 1 N PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ TLY CLOSED SITE � ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY 517E CLOSURE G � I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) ul J�1• FACILI !SITE NA CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Box to indicate Ll PARTNERSHIP ❑ STCEAGENCY �yyyrrrr /� p J ❑ CORPORATION LlLOCAL-AGENCY ❑ FEDERAL-AGENCY /�'] +� l- 66S r �s ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP ODE SITE PHONE#.WITH AREA CODE TYPE OF BUSINESS, ❑ 2 DISTRIBUTOR ❑ 4 PR ESSOR ✓Box if INDIAN EPA ID # ❑ ❑ TRUSRVLANDS or ❑ n/G 1'l�C� �ATTHISSITE afi TANK' .�°L 1 GAS STATION 3 FARM OTHER �/1!J EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE rhAnLP 104 0 0 - 3 _ NIGHTS: NAME(L-AST RRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S T rl . MAILING or STREE A DRESS ✓Box to indicate ❑ PARTNERSHIP F3STATE-AGENCYLc? 11CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY la vLe, ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAM STATE ZIP CODE PHONE N,WITH AREA CODE to(�l'uz a p_" a III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION KFJ MAILING or STREET ADDRESS v Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INOVIDUAL 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ R. ❑ 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 FPERMiR JURISDICTION# AGEN'CY# FACILITY ID# #of TANKS at SITE 13H 1 1 11 1:1 1 1 lnlolll (�- 141L] ion AGENCY FACILITY ID# APPROVED BY N ME PHONE k WITH AREA CODE PERMIT PPROYAL ATE PERMIT EXPIRA Io iakr � ! ca CENSUS TRACT kSUPE VISOR-DISTRICT CODE BUSINESS P N FILED DATE FILED YES � NO PERMIT AMOUNT SUR ROE A UN FEE CODE RECEIPT 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 4 �-�