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STATE OF CALIFORNIJW WATER RESOURCES CONTRONOARD FORM `A': _ �o z UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o COMPLETE THIS FORM FOR EACH FA LITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I'a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Plql I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) }CDJ. FACILITY/SIT AVE CARE OF ADDRESS INFORMATION S �riey ADDRESS NEAREST CROSS STREET ✓ Yale ❑ PAWNEPSHIP ❑ STATE AGENCY ODWRATION Cl LOCAL AGENCY ❑ FEDERAL AGENCY ❑ INWOUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE /LI�iI eco✓ CA TYPE OF BUSINESS: ❑ p DISTPISUTOR ❑ 4 P SSOfl ✓Box i11NDIAN EPA ID p ,,�- ' s Mot TANK'e RESERVATION or ❑ E/f/Y`^� AT THIS SITE / ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) y PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE ft WITH AREA CODE y{J/ L NIGHTS: NAMEILAST FIR ) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME I CARE OF ADDRESS INFORMATION lb T ✓ cv MAILING TRE ADDRESS ✓eo In, ❑ PARTNERSHIP ❑ STATE-AGENCY A ,/ / RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Ap 67 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP COUE PRNE 4 ITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME z CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/B..to ATIle 11 PARTNERSHIP ClSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME 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: I. 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE our CURRENT LOYAL AGENCiFACLI Or APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION C DE CENSUS TRACT# SUPERVISOR-D STRICT CODE BUSINESS PUN FILED DATE FI D D /1 YES NO CHECK# PERMIT AMOUNT SURCHARG AMGUN FEE CODE RECEIPT# BY: 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 0 Y. FORM A(3-2-88) 0 DATA PROCESSING COPY