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STATE OF CALIFORNIA WATER RESOURCES CONTROXIARD r 5e�`""" l`•`A FORM `A': UNDERGROUND STORAGE TANK PROGRAM � o SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PER 5 CHANGE OF INfORMAT10N ❑ 7 PE NTLY CLOSED SITE 1-'L ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) CT1 O FACILITY/SITE NAME CARE OF ADDRESS INFORMATION IAII SS I ADDRENEAREST CROSS STREET ✓ roiNDce D PARTNERSHIP Cl STATE AGEN9 CORPORATION D LOCAL-AGENCY D FEDERAL-AGEN9 V r ( ❑ INONIOU/L ❑ COUNTY AGENCY CITY NAME ^ K� STATE ZIP CODE o� SITE PHONE p,WITH AR jA CODE TYPE of BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N N of TANK'SRESERVATION 5 9 ❑ 1 GAS STATION [:]3 FARM OTHER TRUST(LANDS or ❑ 1 W ✓�- 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 i i Ckivt� i Ke- L 1047 /oS� Ble G Ok ; - D NIGHTS: NAME(LA ,FIp ��RS�T) PHONE WITH AREA CODE NIGHTS: NAME(LA ,FIRST) ONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION GC a APs o MAILING or STREET ADDRESS ✓RWto indicate 11PARTNERSHIP 11STATE-AGENCY CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY it � AZO �,(G D INDIVIDUAL D COUNTY-AGENCY CITY NAME SZIP CODE'7O ' PHONE#,WITH AREA CODE Ctq Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) (/�' -- NAME CARE OF ADDRESS INFORMATION S n MAILING or STREET ADDRESS ✓ ox toindicate D PARTNERSHIP D STATE-AGENCY CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS II. 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE m 10 10 1 / f7a 10001 CURRENT LOCAL AGENCY FACILITY NO N APPROVED BY NAME PHONE N WITH AREA CODE Z4 11,9((L a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED O TE FILED d ) YES NO /3 g CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 0 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY