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STATE OF CALIFORNIA WATER RESOURCES CONTR(^edOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Y '"� .6, �� o COMPLETE THIS FORM FOR EACH FACILITY/SITE � L MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM! TLY CLOSEDSITE FJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 63 N I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 00 IV FACILITY/SITE NAME CARE OF ADDRESS INFORMATION L, ADDRESSI ^ RA NEAREST CROSS STREET ✓Box loinmcat, El PARTNERSHIP ElSTATE-AGENCY ,pC El CORPORATION 1:1 LOCAL-AGENCY ❑ FEDERAL-AGENCY Im vii, C ate• I1!!` w ! El INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMESTATE ZIP CODE SITE PHON It,WITH AREA CODE CA X33 C;1,o9 A39— 31167 TYPE of BUSINE S ❑ 2 DI TRIBUTOR ❑ 4 PROCESSOR [RESERVATION x if INDIAN EPA ID # or #of TANK'sI GAS STATION 3 FARM ❑ 5 OTHER LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE 7 NIGHTS NAME(LAST,FIRSTY PHONE74 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ 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 S crivti•.e_ Q s �a �- MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE if.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. ❑ 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 If AGENCY# FACILITY ID# #of TANKS at SITE EM I I 1 -1 El 1 1 161014 k)-1d D 1(0 l CURRENTF L NCY FACILITY ID/1 _]__APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER 1,'/`l '/—✓1"��•`(f PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRAM SUPERVISOR-DISTRICT CODE BUSINESS S N FILED NO ❑ DAR��Vff E FILED 1717 �3, CHECK# PERMIT AMOUNT SURCHARGE 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(3-2-88i � �' DATA PROCESSING COPY