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STATE OF CALIFORNIA w ATER RESOURCES CONTROLOARD /� "��•�R. "F FORM `A': UNDERGROUND STORAGE TANK PROGRAM 3 3m SITE /� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z L Yra 1 Q COMPLETE THIS FORM FOR EACH FACILITY/SITE �'4LIF0Ry p MARK ONLY ❑ 1 NEW PERMIT 113 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM LOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CL FPILI /r/SI��T& ME /JCAR DRESS INFORMATION ADDRESS l / !EPA EST SS STIR ✓BOXIOMMID ❑ PARTNERSHIP ❑ STATE-AGENCY �, ix ❑ CORPORATION ❑ LOCAL-AGENCY F EHAL-A N❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME r ZIP CODE ITE PH E#,WIITHHAREACODETYPE OF EIUSINESS' A �� 0 ©❑2 OIS7RIBUTOR 4PROCESSOR ✓Box ii INDIAN n ❑ 1 GAS STATION [—] 3 FARM ❑ 5 OTHER RESERVATION or #of TANK's /� TRUST LANDS ❑ AT THIS SITE04-- EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY,: NAME(LAST,FIRST) PHONE#WITH AREA CODE DASA. NAME(LAST,FIRST) fL/1 G 1G/�1 PH'Q�JN WITH AREA CODE 3 3'Y`3*3-C yyJJ(f/ NIGHTS, NAME LAST,FIA T) - PHONE M WITH AREA CODE NIGH fi: NAME(LAST,FIRST} PH9,,NE 0 WITH AREA CODE II. PR PERTY WNER INFORMATION & ADDRESS - (MUST BE COMPLETED) N16 CARE OF DDRESS INFORMATION qorS 1iMAILIT ADDRESS ✓Box to indicate ❑ PARTNERSHIP ENCY lLol Clj � El El ❑ LOCAL-AGENCY 13FTDER A GAGENCY Cf ME * ^'� El INDIVIDUAL ❑ COUNTY-AGEN_GY STA-(A ZIPC&DE PHONE N,?T AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAM GAFEAD DRESSINFpRMATION MAI ING or ST E J T ADDRESS I C,/•V^/ ,A`+✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Q� Vo ❑ COHPORATION ❑ LOCAL-AGENCY ❑ INDIVIDUAL ZIP CO❑ COUNTY-AGENCY OERAL-A ENOY CITY NAME 5 STAT DE PHONE ITN 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. ❑ if. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE _LL] L7 D CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY N M PHONE#WITH AREA CODE ,."IF 3� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED ^1 JATE /FILED F! YES ❑ NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON FORM A(3-2-88) 0 DATA PROCESSING COPY