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STATE OF CALIFORNI0 WATER RESOURCES CONTRGQOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE I-a ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE �'� ^J Cn I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A FACILITY/SITENAME j CARE OF ADDRESS INFORMATIgN a) /A"1/b S ., ADDRESS nJ / NEAREST CROSS STREET ✓fBlor�g��'AAid" ❑ PARTNERSHIP ❑ STATEAGENCY ON 13 ON S. N /NK"%1/ Gu/�� ILrINONIDIATI' ❑ COUNTY CY ❑ FFDE0.4l AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE S46 CA .ZGg_ <1 " TYPE OF BUSINESS: ❑2 ISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID a ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION or - #of TANK'# ❑ TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE P - S b NIGHTS' NAME(LAST,FIRST) PH NE#WITH AREA CODE NIGHTS NAME(LAM) PHONE A WITH AREA CODE IUOp ef?-W- Lam' II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMA ION o � z` A �" 6 /S MAILING or STREET ADDRESS to indicate 13PARTNERSHIP ❑ STATE-AGENCY "�,, SN AT,iV�A.lx CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENGY CITY NAME 13STATE ZIP CODE PHONE A,WITH AREA CODE w e r_,¢ (, III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME (� CARE OF ADDRESS INFORMATION MAI U NG or STREET ADDRESS I/Box to indicate ❑ PARTNERSHIP Cl STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE q,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 KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION Al AGENCY k FACILITY ID# #of TANKS at SITE 00 Z CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE K WITH AREA CODE Q PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE rOCATIONCODE CENSUS TRACT If SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3.Z$ YES NO ❑ECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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(3-2-88) DATA PROCESSING COPY 0