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_ .., ._. ., �. '" � .{_:.. 1..*ea•,trt:�' F� ^vim+ RNIP WATER RESOURCES CONTR&OARD i, STATE OF CA FO FORM `A': UNDERGROUND STORAGE TANK PROGRAM l o 9 SITE AGILITY/SITE, INFORMATION and/or PERMIT APPLICATION Aon/ Z 011 COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT L_xCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIT ONE ITEM ❑ 2 INTERIM PER ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Q� FACICRY/SITE NAME CARE OF ADDRESS INFORMATION YYIRN Mf r- GU SOfY'A�SP� NEAREST CROSSi2w C LOCAL-ADENPARTNEFGHT C FEDETAL AGDI ENU ADDRESS ClN ❑ LOCAL-AGENCY ❑ FEOEAAL�AGENp I g50 F RC� S' 6– INDIVIDUALC COUNTY AGENCY CITY NAME STATE ITE PHONE p,WITH AREA CODE L 1 C CA 9 —0/23 TYPE OF BUSINESS: EPA ID x ❑ 2 DISTRIBUTOR 4 PROCESSOR RESERVATION or N o1 HIS SI ❑ I GAS STATION ❑ 3 FARM ❑ 5OTHER TRUSTLANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE F WITH AREA CODE 5a,PA s�N 2o9-?S3—p/�3 NIGHTS' NAME(LAST,FIRRT) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE rbuc r_ P/ov Zoa-8�'-3-30hr 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION oor MT_6_ I 4INDIV"ODUAL MAILING or STREET ADDRESS tintlic le ❑ PARTNERSHIP ❑ STATE-AGENCY RRATION C LOCAL-AGENCY ❑ FEDERAL-AGENCY CAQOk Cl COUNTY-AGENCY MP' STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME r�11Q/ CARE OF ADDRESS INFORMATION MAILING or STREET ADORES ✓Box to IocAcate C PARTNERSHIP C STATE-AGENCY Cl CORPORATION Cl LOCAL-AGENCY C FEDERAL-AGENCY C INDIVIDUAL C 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. ❑ II. III•❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. '>J I J APPLICANT'S NAME(PRINTED&SIGNATURE) GATE ✓ h LOCAL AGENCY USE ONLY 75 COUNTY N JURISDICTION R AGENCY k FACILIYYI67F— R o1 TANKS at SITE CURRENT LOCAL AGENCY FACILITY 10 F APPROVED BY NAME PHONE N WITH AREA CODE MOORMOZZ— PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 7 3 �[•— YES NO �( PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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(3-2-88I Q Notf ' ' ��X50 DATA PROCESSING COPY -