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STATE OF CALIFORNIA WATER RESOURCES CONTROLOARD ar_- 46�� 14 F Y__ A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSLO SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE o I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/ NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Smtram Cl PARTNERSHIP D STATE AGENCY ❑ WROMTCN 0 LOCAL-AGM 0 FEDERAL AGENCY ❑ INDNIGUk 0 COUNTY-AGE10 CITY t4ASTATE ZIP ODE SITE PHONE p.WITH AREA CODE C CA 5a v a a-la TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA HD a RESERVATION or M of TANK'F ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST.FIRST PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE C�a9 1 _ NIGHTS: NAME(LAS .FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE Cao9 30 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADD# S — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/so.to inchoate 0 PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BO GAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOT BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) NDATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY# FACILITY IDN M Df TANKS K SITE CURRENT AL AGENCY FACILI 1If APPROV BY ME PHONE#WITH AREA CODE PERMIT HUUMBE PERMIT APPROVAL DATE PERMIT E%PI ATION DATE 3- / 57/ 7E 3/- �/ LOCATIONCOOE CENSUS TRACT SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED o YES NO CHECK# PERMIT AMOUNT SURURAFIGIES AMOUNT FEECODE RECEIPT If BY: 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. �\ FORM (3-2-98) 3- as�� • ��