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STATE OF CALIFORNI.0 WATER RESOURCES CONTROL0ARD � "e FORM `A': UNDERGROUND STORAGE TANK PROGRAM ° SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ~° ; 10 COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT In5 CHANGE OF INFORMATION ❑ 7 TLY CLOSED SITE ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r� I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N FACILITY/SITE NAM CARE OF ADDRESS INFORMATION ADDRESS EAREST CROSS STREET xlamute ❑ PMITNEHSHIP ❑ STATE AGENCY J 6 S WI° Sri CORPORATION EJ LOCAL-AGENCY 13 FEDERAL AGENCY VVVV / ❑ INDIVIDUAL 11 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE STS CA TYPE OF BUSINESS: ❑ p DISTRIBUTOR �ROCESSOR ✓BaX if INDIAN EPA ID # ❑ 1 GASSTATION ❑ 3 FARM 5 OTHER TRUST LANDS Dr ❑ #of TANK'I AT THIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: 14E(LAST QRST)/ Pf�PHONEWITH AREA CODE DAYS: NAME(LAST,FIR A PHONE R WITH CODE XeN 21 NIGHTS: NAME(LAST,FIRST),/• PHONE N WITH AREA CODE NIGHTS: NAMEME(LAS�T,FIRS/� /^7 / PHONE#WITH AREA CODE v✓� II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S &A of, A-S 1 MAILING or STREET ADDRESSox lc lndicale ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY LJFEDERAL-AGENCY INDIVIDUAL Cl COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 21~(,k DEQ a MAILING or STREET ADDRESS ox To indicate ❑ PARTNERSHIP ❑ STATE-AGENCY J, CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCYV, O "1 L ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIPCODE IRON # WITH REA CODE S o�I�7�,✓ CA 5_20 / 6 - IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at S1TE 39 © � / 1 1010101/1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE A� PERMIT EXPIRATION DATE /L 27 LOCATION CODE CENSUS TRACT SUPERVISOR- STRICT CODE BUSINESS PLAN FILED DATE FILED YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUSTSE ACCOMPANIED BY AT LEAST(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