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STATE OF CALIFORNIP WATER RESOURCES CONTROROARD v' FORM `A': UNDERGROUND STORAGE TANK PROGRAM , "o 71 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED SITE r ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 50 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) ODD FACILITY/SITE NAME(1,^^ ` CARE OFRESS INFORMATIO�Ny� I C ADDRESS NEAREST CROSS STREET `✓ xlouxlicale ❑ PARTNERSHIP ❑ STATE AGENCY I , '^ + I RPoR1AiIDN Cl LOCAL AGENCY [I FEDERAL AGENCY 9-1 ( V • �� ❑ INDIVIDUAL ❑ COUNTY'AGENCY CIN NAME �� STATE ZIFAODE SITE PHONE ft,WITH AREA CODE 1 cA (j1 X20 Uq L TYPE OF BUSINESS: ❑ p DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID a RESERVATION or N of TANK's ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(—AST.FI^RST) PHONE K WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) — PHONE#WITH AREA CODE f`\� a, ac)a (StP S II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREETADDRE55 py © l ,.L/�, ✓Box to edcate ❑ PARTNERSHIP ❑ STATEAGENCY S�1 F OIJS.A" 0 CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STAT ZIP ODE PHONE 4,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME ^^ nn CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL D 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. ❑ Ila. 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 fY JURISDICTION N AGENCY M FACILITY ID N N of TANKS at SITE 3 q = = I o I 0 I 2- Z 1 o a 1 0 CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE A WITH AREA CODE P� 1aLO-F- 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED D I 3 20 YES NO CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE AC"OMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIO LY. FORMA(3-2-81 .10 DATA PROCESSING COPY 0 `