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STATE OF CALIFORNIA WATER RESOURCES CONTROL i #RD �� `� �`�•°"''� FORM `A': " UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F4CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER NCI�SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /VV}} I.FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS / N STCROSSSTREE7 P ✓BEl OWMTte ❑ tOCX-AG ❑ FTAFE-A-AG Cl IOVOJAL ❑ COI/m-AGE v ElR IAL ' CITY NAME STATE ZIP CODE SITE PHONE M,WITH AREA CODE L CA sod I O TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box H #EPA ID q RESERVATION or X o}TANI('a ' ❑ I GAS STATION ❑3 FARM OTHER TRUST(ANDS F7AT THIS SITE �J EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE it WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE II WITH AREA CODE i NIGHTS: NAME(LAST,FIRST) NeHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. 'PROPERTY OWNER INFORMATION & AD RESS - (MUST 13E COMPLETED) NAME CARE Of ADDRESS INFORMATION y ' 'a&Z, MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY — i� ❑❑� ppl!��PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY I NDRI )UAt ❑ COUNTY-AGENCY CITY NAME STATEZIP CODE PHONE N.WITH AREA CODE ^ I 111. TANK OWNER INFORMATION &ADDRESS - (MUS E COMPLETED) NAME�� /I� QE OF ADDRESS INFORMATION SZ, MAILING or STREET AD ESS �•i�� I / ✓B o' dicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ C RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY w DIVID L ❑ COUNTY-AGENCY CITY NAME STATE NIP CODE PHONE 0,WITH AREA CODE C/4 is o ' IV. LEGAL NOTIFICATION ND BILLING ADDRESS CHECK ONE(1)BOX INDICATING INN10N AWWR ADORMIMtt!SHOULD 13E USED FOR DOW LEGAL NOTIFICATION Ahu v"ING: I. ❑ II. ❑ k!I-❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOrroFDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED L SIGNATURE) DATE LOCAL AGENCY USE ONLY FLOCATION Y S JURISDICTION M AGENCY M FACILITY ID 1i k o1 TANKS at SITE � Q � 11114 LE-Lo TO Y� AL AGENCY FACILITY ID APPRO D BY NAIVE PHONE WffW AREA CODE �'. o a. 15-1 ER PERMIT APPROVAL DATE PERMIT EIIPIRATION DATE DE CEN B TAAC�� SUPERY� STR�CODE BUSIN04 PLAN FILED DATE FILED 6% YES ❑ NO ❑r PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY: i THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'S'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1/-1 ; RMA(3