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STATE OF CALIFORNI10 WATER RESOURCES CONTRALBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM � o SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;: COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE { ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1 '0 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) / GOA FACILITY SITE NAME CARE OF ADDRESS INFORMATION ,v r Q.YV1�i CD 70'0 DDRES NEAREST CROSS STREET ✓HPRO i Cl PARTNERSHIP 1:1 STATE AGENCY W' ❑�� GO�8APIpN ❑ LOCAL AGENCY ❑ FEDERAL AGENCY jcm ❑ COUNTY-AGENCY CIN NAME STATE ZIP C E SI E PHONE#,WITH AREA CODE TYPE OF BUSINE ❑ p DISTRIBUTORR ❑ 4 P4 PROCESSOR ✓Box if INDIAN EPA o #A �a`d a 0 O ❑ 1 GASSTATION ❑3 FARM THER RESERVATION or ❑ #of TANK's TRUST 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 01-11 i ' NIGHTS: NAME(LAST,FIRST) e, --____'Lww HONE#WITH AREA CODE NIGHTS: NAME(LA6T,FIRST) PHONE#WITH AREA CODE S ^^Y// AB � II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME C aCARE OF ADDRESS INFORMATION V MAILING or STA ET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME s /7/� / y�� CARE OF ADDRESS INFORMATION iii✓�.s/ MAILING or STREET ADDRESS ✓BOx to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY 11 INDIVIDUAL ClCOUNTY-AGENCYCITU NAME STATE ZIP CODE PHONE p,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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE D N3 Q CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME w11 ' PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE rCH TION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED KN PERMIT AMOUNTO SURCHARGE AMOUNT FEE CODE YES ❑RECEIPT MNO ❑ // 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) Iti 0 DATA PROCESSING COPY 0