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STATE OF CALIFORNIA WATER RESOURCES CONTRONOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM AL SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FA ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ Y CLOSED SITE/� I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME -+ CARE OF ADDRESS INFORMATION /VoJ�V/t GAN. ADDRESS / - -/ NEAREST CROSS STREET [I CORPORATION 11PA�NE�I� O FEDERAL-AGENCY ❑ INOMWAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE CA -f-3 ,3 d-- X;23-6 7 TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ /PROCESSOR ✓Bax it INDIAN EPA ID NRESEM of TANK1 ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTMLANDS ATION D ❑ AT TNI$SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 MAILING or STREET ADDRESS ✓Box to Intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. ❑ it. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N IIr""AGENCY# II FACILITY ID N R o/TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DIS ICT CODE BUSINESS PLAN FILED DATE FILED _ C Z�--LZy-. lei YES NO QHS CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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. FOR.A(3-2-88)