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STATE OF OAfFORNI WATER RESOURCES CONTROL'S ARD {` FORM 'A'. UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH!-�CILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PER NTLY CLOSED SITE ONE ITEMI ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ' I FACILITYISITE NAME CARE OF ADDRESS INFORMATION i ADDRESSp ^} NE EST CROSS STREET o ✓Bm 10 cdra,e ClE�ILY F9MfJR5HI? ❑ Sf ITE-AG ) S fin— f © `COLPM G ° ` Ru-ucE� cr CITY NAME STATE - ZIP CODE SITE PHONE A.WITH AREA CODE 4 L �-C1vL CA _52% O TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PRDCEM ✓Box i1 INDIAN EPA ID r ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS SERVATION of ❑ 1:0TTHISSITE TA x EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) i DAYS: NAME(LAST,FIRST) PHONE to WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE q WITH AREA CODE NIGHTS: NAME(LAST.FIRST) ONE r WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE r WITH AREA CODE 11. PROPERTY OWNER INFORMATION & AD KESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY , NDI4tDUAL ❑ COUNTY-AGENCY C1TYNAME STATE ZIP CODE PHONE M,WITH AREA CODE cl III. TANK OWNER INFORMATION &ADDRESS --- (MUS E COMPLETED) r NAME hlaAw pE Of ADDRESS INFORMATION MAILING or STREET AD ESS /� ✓XQDFR'IATION afe ❑ PAATNERSHIP I❑ STATE•AGENCY t ly ❑ ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY L ❑ COUNTY-AGENCY STATE ^ IP CODE O PHONE N.WITH AREA CODE CITY NAME f C,�Jj k IV: LEGAL NOTIFICATION ND BILLING ADDRESS i' CHECK ONE(1)BOX INDICATING WHICH ADM AODIIIISS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION Ahv LALLING: L ❑ IL ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOvv*FDGE,IS TRUE AND CORRECT. ! e, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE I LOCAL AGENCY USE ONLY COUNTY A JURISDICTION r AGENCY# FACILITY ID M Not TANKS tM SITE F7 Ij I I _L-1I i C� d �- 12/ lc--::) teTo 1 !;� CURRENT OCAL AGENCY FACILITY Ip APPROV D BY NAME PHONE r WITH AREA CODE o r� O t PERMIT NUMBER PERMIT APPROVAL DATE PERMIT>:MRATION DATE LOCATION CODE C S 7'RABUP r ERV COD! BUSINE88 D ❑ DATE fILEp 1 3 YES NO CHECK rPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT r BY: ' � 4 THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.. kI RM A(3-2-68) �� — f � d i � ��