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or 1 STATE OF CALIFORNIA WATER RESOURCES CONTROOOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� l/ COMPLETE THIS FORM FOR EACH FA ILITY/SITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 14frHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS ! NEAREST CROSS STREET ✓ CdM 11PAKNOWIP ❑ STATEAGE%Y R/l ATIGN LOCAL-AGM 11FEGEPAL-AGENLY Cl INGIVIIw ❑ COUMINTY#GBICY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA 95.70 YG/ TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz If INDIAN EPA ID N Not TANMN TT1 RESERVATION or �.p a 3 AT THIS SITE V E] I GAS STATION E]3 FARM EDS OTHER TRUST LANDS ❑ C.9G 9"9/& 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 r' - y6 Y o SA iyL NIGHTS. NAME(LAST.FIRS ) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE q !/ II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION oinIcate ❑ILING or STREET ADDRESS PtePARTNERSHIP 1-1 STATE-AGENCY 11 ND VIDUAtlLION ❑ COUNTY-AGENCY 13 LOCAL-AGENGY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA ODE ac E ij III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION mC MAILING or STREET ADDRESS IV ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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. ❑ IL ❑ 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 If SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY R FACILITY ID N q � N of TANKS at SITE CID " U Z? CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CEN8U8 TRACT N BUPERV180R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED D Q 3a�+J YES NO IN CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: nn v' THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION UNLESS THIS IS A CHANGE OF SITE INFORMATION 757 q FORM A(3-2-88) I � I1 � C7 ,c�U