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. ._,R,iri1'+'3;,�i6"*'71�'W'9P�Rov3y�ecaraw.•..,y�Rpn.�.. mAr•7^^. . . �. ._t, �. . _,--.. .v.'..... ,..+�, •,s.' „-a��""a-•—m'< -.. ., STATE OF CALIFORNIP WATER RESOURCES CONTROLOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM u � SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE O4U FOaN�P 'M1'L MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 1:16 TEMPORARY SITE CLOSURE C3 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) v FA LITY/SITE NAME //, / CARE OF ADDRESS INFORMATION Ou`S PrAl4we 111 /N(1,/7 G"NAiJ j k-- SON ADD ESS NEAREST CROSS STREET ✓Soxlo indirale ❑ PARTNERSHIP ❑ STATEAGENCY ?07 J"7 /J / ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDi AGENCY PN 7]N�Pi��+JN ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE Sta �1a� CA 9��0/ TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ d PROCESSOR I/Box it INDIAN EPA 10 # RESERVATION or #DI TANK'# ❑ I GASSTATION ❑ 3 FARM ❑ 5OTHEA TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to odicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 21 it. ❑ 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE 39 = = I 1 1av CURRENT LOCAL AGENCY FACILITY ID# - APPROVED BY NAME PHONE#WITH AREA CODE 13 R ys<�) o PERMIT NUMBER - PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST V MORE TANK PERMIT FORM `B'APPLICATION(S), UN S THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY `