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STATE OF CALIFORNIA WATER RESOURCES CONTROL9OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION CCOMPLETE THIS FORM FOR EACH FACILITY/SITE WP. `Ay r prj-9 Cq�IFORNxP MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT F54� CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 2n I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION - CARE OF ADDRESS INFORMATION ✓ Box to indicate El PARTNERSHIP � r ►S. EI ❑ LOCAL -AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NA ADDRESS CODE PHONE #, WITH AREA CODE NEAREST CROSS STREET ✓ Box to indicate El PARTNERSHIP ElSTATE-AGENCY 1�� BUSINESS PLAN FILED � NO �7—CK DATE FILEDYES ,' / ` ❑ CORPORATION ElLOCAL-AGENCYElFEDERAL-AGENCY C.� __[FEE CODE W ❑ INDIVIDUAL ❑ COUNTY -AGENCY u—Nie— CITY NAME STATE ZIP CODE SITE PHONE 4, WITH AREA CODE O CA 7/- 5 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSORPRUSTLANDS /Box if INDIAN EPA ID # ❑ 1 GAS STATION ❑ 3 FARM ®'5 OTHER ESERVATION or ❑ �- # of TANK's AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRS ) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGH : N (LAST, FIR T) PHONE # WITH AREA CODE NIGHTS. NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPE TY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME -3 Awisles CARE OF ADDRESS INFORMATION - MAILINQ or TREET RESS ✓ Box to indicate El PARTNERSHIP ❑ STATE -AGENCY 7u EI ❑ LOCAL -AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NA STATZIP CODE PHONE #, WITH AREA CODE LC CENSUS TRACT ##SUPERVISOR 1�� BUSINESS PLAN FILED � NO �7—CK III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME n C� � S� CARE OF ADDRESS INFORMATION - MAILING `TREET ADD SS ✓ Box to indicate 1:1CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ LOCAL -AGENCY E] FED A -AGENCY ❑ COUNTY -AGENCY CITY NAME STATE '74-_ PERMIT APPROVAL DATE ZIP CODE PHONE #, 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. 19 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # %� %) FACILITY ID # # of TANKS at SITE �) r /171(017--1 d RENT LOCAL AGENCY FACILITY ID # �S [IERMIT APPROVED BY NAME PHONE # WITH AREA CODE NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ATION CODE CENSUS TRACT ##SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED � NO �7—CK DATE FILEDYES # PERMIT AMOUNT SURCHARGE AMOUNT __[FEE CODE RECEIPT # BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAS? (1) OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA (3-2-88) 0 DATA PROCESSING COPY 6 10 IV a) kill