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NATE OF CALIFORNIA* WATER RESOURCES CONTROLOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) �S�PIO`\TM 1 1 n N Aft l z `• o ��'i�J•r i 1C C9G�p0 RN�PI 7 PERMANENTLY CLOSED SITE rAau IY/SITE N E JURISDICTION # I 1 1-:1 CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY NEAREST CROSS STREET ✓ Box to ndicale ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ ADDRESS A j Cl INDIVIDUAL Cl COUNTY -AGENCY CITY NAME STATE LOCAL -AGENCY ❑ FEDERAL -AGENCY CITY NAM SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO ❑ ❑ INDIVIOUAL ❑ COUNTY -AGENCY CHECK # PERMIT AMOUNT STATE ZIP CODE SITE PHONE a, WITH AREA CODE FEE CODE RECEIPT k CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID a ❑ I GAS STATION ❑ 3 FARM ❑ 5 07HER RESERVATION or ❑ k of TAN TRUST LANDS AT THIS SITE SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE k WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE a WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE k WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE a WITH AREA CODE Ii. PROPERTY OWNER INFORMATION P. AnnRFcc — glut ICT me r•nam, to=Tor%% III. TANK OWNER INFORMATION & ADDRESS — flat ICT Rl= enfucl cTcn% NAME JURISDICTION # I 1 1-:1 NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY APPROVED BY NAME PHONE k WITH AREA CODE Cl CORPORATION ❑ LOCAL -AGENCY Cl FEDERAL -AGENCY Cl INDIVIDUAL Cl COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE a, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — flat ICT Rl= enfucl cTcn% NAME JURISDICTION # I 1 1-:1 AGENCY # E[ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP Cl STATE -AGENCY APPROVED BY NAME PHONE k WITH AREA CODE ❑ 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: I. ❑ 11. ❑ 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 # Ea JURISDICTION # I 1 1-:1 AGENCY # E[ FACILITY ID # # of TANKS at SITE L M��f5l D 107071 CURB NT LOCAL AGENCY FACILITY I # APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUM ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT k SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO ❑ DATE FI ED -� ��_�%, CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k 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 NLY. \� ORM A (3-2-88) \ ` DATA PROCESSING COPY l