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STATE OF CALIFORNIA FORM `A'• 0 Vit: ,ILAW WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PROGRAM SITE a FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE FOR MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / bW I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) o FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION hlCp �= .r/ m S /-?-- . ✓ x to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ADDRESS MAILING or STREET ADDRESS NEAREST CROSS STREET ✓ Boz to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY 2 ' ' ' } Q CORPORATION ❑ INDIVIDUAL El ❑ FEDERAL AGENCY J 3(� (N / /` / fid% )eel' ZIP ❑ INDIVIDUALION ❑1:1 COUNTY -AGENCY CITY NAME CHECK # STATE ZIP CODE SITE PHONE #, WITH AREA CODE f'�v9 s yy-33�o RECEIPT # CA y'!5�3(o c 0? - 5Y y -_?;''o TYPE OF BUSINESS: ❑ 2 DI IBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN or EPA ID # # of TANK'a .y ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE le de NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) • 0 NAME CARE OF ADDRESS INFORMATION f�. L Li I✓ll ! bi A- e, � f /r.) MAILING or STREET ADDRESS ✓ x to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILING or STREET ADDRESS ✓ 50<10 indicate ❑ PARTNERSHIP ❑ STATE -AGENCY 3 3 (� , / 7 �j,j �• CORPORATION ❑ INDIVIDUAL ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE CHECK # 61i4 1 9'_6_34-4 f'�v9 s yy-33�o RECEIPT # BY: III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION f�. L FACILITY ID # ` q I I q 1 MAILING or STREET ADDRESS ✓ x to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ET CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY [ / ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE LOCATION CODE ( d,< CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO ❑ 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 & SIGNATURE) DATE I eknAI ArrFNl`V IICF InNI v COUNTY # 3El JURISDICTION # AGENCY # F -I FACILITY ID # ` q I I q 1 # of TANKS at SITE O A012 CURRENT LOCAL AGENCY FACILITY I 1�� AOPROVE PHONE # WITH AREA CODE pE !�!�� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE ( d,< CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO ❑ DATE FILED CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY: TFT 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 A (3-2-88) y DATA PROCESSING COPY