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STATE OF CALIFORNIV WATER RESOURCES CONTRABOARD w. FORM A: UNDERGROUND STORAGE TANK PROGRAM = SITE /FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l/ COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER TLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE $O I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME R R CARE OF ADDRESS INFORMATION S I 1 ADDRESSQ-_ ..{/_ NEA EST CROSS STREET ✓Bm �e 0 PA6fNR$HP 0 STALE AGENCY C // 97M 0 LOCAL 0 FEDERAL.AGENCY V / WL.t%/�' /L74� INDMDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHOP,WITH AREA CODE TYPE OF BUSINESS: 2DISTRIBUTOR CESSWR ✓BOX if INDIAN EPA ID# ❑ ❑ #RESERVATION or - of TANKY ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS El AT THIS SITE Q� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE#WIITTHH AREA CO DAYS: NAME(LAST,FIRST PHONE N WITH AREA CODE Pt'eu�A-� �GLN 6 7 S NIGHTS: NAME(LAST,FIRST PHONE#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 �.4� D/ el; F ecrRfm. Rc JO MAILING or STREET ADDR SS ✓Bo to ietlicele ❑ PARTNERSHIP 11STATE-AGENCY ORPORATION 0 LOCAL-AGENCY 1:1FEDERAL-AGENCY INDIVIDUAL 000UNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION #x s MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID If #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE S s-r_�� 6 0 Gr/ PERMIT NUMBER PERMIT APPROVAL DAY E � PERMIT EXPIRATION DATE 2 y LOCATION CODE CENSUSTRAQT#` SUPERVISOR- (STRICT CODE BUSINESS PLAN FILED DATE FILED YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: - I 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. W FORM A(3-2-88) to (/ DATA PROCESSING COPY )