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STATE OF CALIFORNIA9 WATER RESOURCES CONTRO0ARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION end/or PERMIT APPLICATION '< a COMPLETE THIS FORM FOR EACH FACILITY/SITE 1 NEW PERMIT 3 RENEWAL PERMIT G 5 CHANGE OF INFORMATION 7 PERMAN �_C [_�;ARK ONLY ❑ ❑ ❑ ONE ITEM ❑ 2 INTERIM PERMIT- ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ®®✓ ilNrab D PMTMMO 0 STATE AGENCY _ �'.5 �� C�L'e {rn ill L,i ❑ w ouk D LOCAL,ABGEN ❑ FFDRVL-AGFrLY N Sr' - OMMT D LOCAL O a GI IY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PNCESSOR ✓0oN if INDIAN EPA ID N RESERVATION or S of HIS SITANK'TE ❑ I GASSIATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE — EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. N ME(LAST, IRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE Y WITH AREA CODE II. PROPERTY OWNER INFORMATION 6 ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAII INC o,STREET ADDRESS ✓ o indicale D PARTNERSHIP D STATE-AGENCY _ [PCORPORATION D LOCAL-AGENCY D FEDERAL AGENCY 0 INDIVIDUAL Cl COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION d DDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MrtIUNG w STREET ADDRESS ✓Box loindicate D PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION D LOCAL AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME - STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADORBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED b SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N IrrJURISDICTION M AGENCY F FACILITY ID E S of TANK$d 817E 5 iJ CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE I WITH AREA CODE �' JLfCif' y-s— PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO 7/,�(b�5'C {, CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORK MUST BE ACCOYIPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ` FORM A(3@ 881