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STATE OF CALIFORNIO WATER RESOURCES CONTRO 0ARD W. FORM `A': ��• .; -m UNDERGROUND STORAGE TANK PROGRAM SITE /► FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , o �T COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 21 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-a ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 9"9 00 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) -4 F+ FACILITY/SITE NAME CARE OF ADDRESS INFORMATION r sons finef d it ADDRESS NEAREST CROSS STREET ✓ Yoxaie ❑ PAAINMIP 0 STATE- AGENCY (7 7 5. G(7!/S DA bO l!'S t7 0 INNDMPOLAL 0 AGEx C( ❑ RGRUL-ACBIa CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE C_ 510 /c fog CA 9sa°i a _ / TYPEOFBUSINESS: ❑ 2 DISTRIBUTOR ❑4 SSOR '/Box N INDIAN EPA ID a RESERVATION or N of TANKY ❑ 1 GAS STATION ❑ 3FARM 50THEA TRUST LANDS ❑ G ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE r snr, ,T.)e !Yi -a8 L(l 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 C! r 6 5o. i MAILING or STREET ADD SS ✓ x to inoicale 0 PARTNERSHIP 0 STATE-AGENCY V CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 5 fvn C-4 1 Quo,7 I (:Pv9-) Y.S/-jam III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ to intlicate 0 PARTNERSHIP ❑ STATE-AGENCY CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY INDIVIDUAL 0 COUNTY-AGENCY CITY NAME / r STATE ZIP CODE PHONE#.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: LEK If. ❑ 111.❑ 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# FA TY IDD N #o1 TANKS at SITE 3 % U ° CURRENT LOCASAOENCY FACILITY IDM PPROVED BY NAME .............CODE L(7[R S O 9 PERMIT NUMBER L DATE PERMIT EXPIRATION DATE LCRECK# CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED q / YES NO k l?l PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: T�IIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ��F/O fM A(3 2 88) ' DATA PROCESSING COPY 5