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STATE OF CALIFORN WATER RESOURCES CONTROARD !,` _.... FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to COMPLETE THIS FORM FOR EACH FACILITY/SITE . MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PER ANENTLY CL SED SITE I"+ ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT S TEMPORARY SITE CLOSURE IV I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) N 4A. FAGUTYISITE NAME CARE OF ADDRESS INFORMATION ccrr s Auy- t ADDRESS /� /� q NEAREST CROSS STREEEETT ✓ilmorosle ❑ PARTNENRIIP ❑ WATEAGENGY to ,;L /V, s wa .SWYI Ctii h�[.l� ❑ InroOMTO ❑ tocu_AGENCY ❑ RUEW ACENc C7 IwMlwa ❑ COUNTY-AGENCY CITY NAME�Q STATCA ZIP CODE SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS: ❑2 DISTRIBUTOR a PROCESSOR ✓Box if INDIAN EPA ID N ❑ 1 GAS STATION ❑3 FARM OTHER RESERVATION TR STLANDSa ❑ /V �JYI�(.� A7TH0 of ASSITE p� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE til1 - NIGHTS: NAME(I-AST,FIRST) HONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE sc��. a 57,7 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION r o r eS MAILINC6%STR ET ADDRESS ✓Boz to inotoate ❑ PARTNERSHIP ❑ STATE-AGENCY I7/ C9RPORATION LOCAL-AGENCY ElFEDERAL-AGENCY Y A DIVIDUAL ❑ COUNTY-AGENCY CITY NAME $TATE ZIP CODE PHONE N,WITH AREA CODE C ao III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 4Q ger 4wu MAILING.STREET ADDRESS v 41 ✓Box 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 BILLIN THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL GE IS TRUE AND CORR APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY IDN N of TANKS at SITE ® = = I o 3 (o F4_670 124 CURRE LOCAL AGENCY FACILRY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMI NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DIST111CT CODE BUSINESS PLAN FILED DATEFILED 3N YES NO � CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: ) THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-83) `� DATA PROCESSING COPY .,�,