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_. �,-_-,r.Trrirvai'm9;.',,;�a�:�'r'eF'�,'.•'-'"e-"s. -t . _ . . - .- '�", .. - � .. .. _, STATE OViCALIFORNI0 WATER RESOURCES CONTROROARD FORM `A': f 'm UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT F__] 5 CHANGE OF$NFORMATiON 7 PERMANENTL LOSED SITE I"a ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME MATION CARE OF ADDRESS INFOR + L ADDRESS NE EST CROSS STREET ✓Bax lairdeale ElPAAT HIP E) STATE-AGENCY Z +l,/�-�� re (J /7 ❑ CORPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY V 1 eSC el Ii 01�VDIYI1�l1AL ❑ COLINTI'-AGENCY CITY NAMEL D � STAT^A ZIP CODE � � SITE of#,WITH AREA CODE �C �{3 TYPE OF BUSINESS: ❑p DISTRIBUTOR F],4 PROCESSOR ✓8ox R INDIAN EPA ID # RESERVATION or R of TANK's ` ❑ 1 GASSTATION ❑3 FARM 5 OTHER TRUST LANDS ❑ — AT THIS SITE I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME{LAST,FIRST) PHONE#WITH AREA CODE DAYS, NAME(LAST,FIRST) PHONE#WITH AREA CODE def_n e.+4e (Ke* a NIGHTS: NAME(LAST,FIRST) 151 PHONE#WITH AREA CODE NIGHTS: NAME{LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME C CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ 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: 1. ❑ it. ❑ ill.❑ 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 Co UNTY fl JURISDICTION N AGENCY M FACILITY ID M M of TANKS at SITE `� a 3 9 OEHCURRT 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-DISTRICT CODE BUSINESS PLAN FILED DATE FILED O c )� L.� YES ❑ NO 3 Vi CHECK N 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 ONL . FORM A(3-2-88) -:.10 DATA PROCESSING COPY 1 .+