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STATE OF CALIFORNI10 WATER RESOURCES CONTROROARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM V SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SI TE FJ ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) 1-t. FACILI TE NAME CARE OF DDRESS INFORMATION N S . T A ADDRESS ^ ' EST CRO SSTR ✓I'Mbi"osle ❑ PARMETSHIP ❑ STRE.AGEgLY ,�[�LjJ1 ❑ GOWRATIGN ❑ LOCAL-AGENCY L. CITY NAMfrr� ❑ INDIVIDUAL ❑ (bU9,WITHA L\' STATE ZIP C E 7517E PHO N,WITHSAR�ODE TYPE OF BUSINESS CA �� 2 o I ']y ❑2 DISTRIBUTOR ❑4 P ESSOR ✓Box if INDIAN EPA ID a ❑ 1 GAS STATION ❑ 3 FARM OTHEfl RESERVATION or //JI R o1 TANK. TRUST LANDS ❑ /�J AT THIS SI EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DrjXS: NA NE I ST,FIRST PHONE k WITH AREA CODE DAYS: NAM (LAST,FIRST) PHO WITH AREA CODE �f( 265 i- a NIGHTS: NAME(LAST!,FIRST) PHONE N WITH AREA CODE NIGHTS: AME(LAST,FIRST) PHON a WITH AREA CODE A II. PROPERTY OWNER INFORMATIO & AD9IRk4w6 - (MUST BE COMPLETED) [NAME4 CARE OF ADDRESS INFORMATION c TREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY SA Cl CORPORATION ❑ LOCAL-AGENCY ❑ RgF 00 (E Cy ❑ INDIVIDUAL ❑ COUNTYAGEGGA CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or ST EET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,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. 19 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 k JURISDICTION N AGENCY R FACILITY ID# #of TANKS at SITE � D 7 b = CURRENT LOCAL AGENCY F UTY ID# APPROVED BY AME PHONE M WITH AREA CODE / Zi PERMIT NUMBER PERMITAPPR VAL PERMIT EXPIRATION DATE Zs 7 LOCATION CODE CENSUS TR7ACT N�j7 UPER SOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE 2 y d V YES NOa� 2 S CHEC M PE MIT AMOUNT SU C ARGEAMOUNT FEE CODE RECEIPT# BY; THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) • ' DATA PROCESSING COPY