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i.' '` ':�E -„ fs,..;.:ev >•..- .;:. .�.qle:Tr x"Ie'+Fy a+re F7-:V.— STATE OF CALIFORNIP WATER RESOURCES CONTROOkOARD " FORM `A': UNDERGROUND STORAGE TANK PROGRAM "'�_' ILL SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OFINFORMATION ❑ 7 PER SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE tJ' t0 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADD ESS INFORMATION ro NEAREST CROSS STREET �✓SOtoto inPAATNEflSHIP ❑ STATE AGENCY N ADDRESS ❑ G ION ❑ LOCAL-AGENCY [IFEDERAL AGEND �vlplOMOUAL ❑ COUNP(AGEND —4 CITY NAME STATE ZIP CODE SIT PHONE N.WITH AREA CODE V CA 3 � �9 57s TYPE OF BUSINESSFR-] 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's BE RE[?<GAS STATION 3 FARM ❑ 5OTHEA TRUSRESETVLATNDS ION or ❑ A///L& AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS N E(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE - W z3�V s a sa l NIGHTS. ME(LASE FIRST) P NE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST ONE 4 WITH AREA CODE oy ,2 - l It. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME - CARE OF ADDRESS INFORMATION ^ ✓Box to indicate 71 PARTNERSHIP L3 STATE-AGENCY MAILING of STREET ADDRESS /, �' V//J/ D CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PH E N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING of STREET ADDRESS ✓Box toladicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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 BILLING: I. II. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE 10 10 1 y1 oIto oL� CURRENT LOCAL AG NCY FACILITY ID# APPROVED BY NA E PHONE At WITH AREA CODE PERMIT NUMBER PERMIT APPROVALDATE PER TEXPIRAT1614DATE LOCATION CO E CENSUS TRACT# S ERVIS -DISTRICT CODE BUSINESS PIAN FILED DATE F17 YES NO CHECK# PERMIT AMOUNT SURC ARGE AMOUNT FEE CODE RECEIPT# B THIS 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. ^ FORM A(3-2-88) Olm DATA PROCESSING COPY .—\J