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STATE OF CALIFORNIP WATER RESOURCES CONTRO BBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM � o SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE �'A'•a^%'" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F"r ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 N I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) ~ A FACILITY/$ITE NAME CARE OF ADDRESS INFORMATION L' _ i a ADDRESS NEAREST GROSS S STREET I/ to idul. [IPARTNERSHIP ElSTATE AGENCY J N. (�j// I�(�/l' (/1! Co I UCORPORATION ❑ LOCALAGENCY 11 FEDERAL-AGENCY ❑ INDMDUAL ❑ COUNIY-AGENC! CITY N ME STATE ZIP CODE SITE PHONE ft,WITH AREA CODE CA 9� ao - TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID n RESERVATION or Mol TANK'S ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ A " ' — AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE G7,nrs GK ao41 bG� NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE If WITH AREA CODE SSG ('aa q 3ro9-5�9 II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME -/-� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ xto intlicate ❑ PARTNERSHIP ❑ STATEAGENCY / n CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY IJ ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE L C/} T50-1.10-5 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME �y �7 �q CARE OF ADDRESS INFORMATION SW i"C � xj MAILING or STREET ADDRESS v ✓Bax to indicate Cl PARTNERSHIP ❑ STATE AGENCY 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE it 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: LX . 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 LOCAL AGENCY USE ONLY COUNTY411 JURISDICTION A AGENCY# FACILITY ID N M of TANKS at SITE M = = 1010 a 7 opo CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE CII PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION ;MUST E CENSUS TRACT SUPERV�ISO[�R-OISTRI T CODE BUSINESS PLAN FILED DATE FI D V 3 r T YES NO CHI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: THIS FORM BE 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-BS DATA PROCESSING COPY 0