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STATE OF CALIFORNI WATER RESOURCES CONTRO01OARD %f '°"" 11 OF FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o z SITE n/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 (� COMPLETE THIS FORM FOR EACH FACILITY/SITE ""°"H,r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P RM CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 f.► I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE N4 w/4l� - /+ CARE 9F ADDRESS INFORMATION ADORE(SS/''V b\��,au-�,�L- gSTATE CR SS STREET ✓Bw loiMicale ❑ PARTNERSHIP ❑ STATE AGENCY 0 con P0R4'ON 0 LGCAL�AGENCY 11DERA4AGFNLY ' 0 INgVIGUAL 0 GAUNIKAGFNCVCITY NAME _ ZIP CODE SITE PH NE M,WITH AREA CODE �/(+ S7:Zb o - 3 J 0 TYPE OF BUSINESS. DISTRIBUTOR 4PROCESSOR ✓Box if INDIAN EPA IDP If ITANK's ❑ ❑ RESERVATION or ^ �) ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ ,JV JV AT THIS 5ITE V EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DA 5: NAME(LAST,F R T) PHONE p WITH AREA 7CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTSM (LAST,FIRST) PHONE N WITH AREA CODE NIGHTS.,NAME(LAST,FIRST) PH NE N WITH AREA CODE S14 S II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or TREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY D FEDERALAGENCY 0 INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 5,1A MAILING of STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP 0 STATE-AGENCY D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS zz 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION S AGENCY R FACILITY IDM M of TANKS at SITE 6 ° 3 po IQ CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE V 6 1 c.3 z z- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATI NCODE CENSUBTRACTM SUPERVI R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 pU l YES NO �! Z/ CHEC If PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: ` THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONS',UNLESS THIS IS A CHANGE OF SITE INFORMATION ON FORM A(3-2-88) DATA PROCESSING COPY