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Sf'.0 OTS ''SF• STATE OF CALIFORNIA C) WATER RESOURCES CONTROL D r FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =" a Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMITCHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE �I ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE qq 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N FACILITY/SITENAME /r CARE OF ADDRESS INFORMATION ADDRESS NEAREST C SS STREET Io iMicaIO ❑ LOCAL QIIP ❑ STATEA AnD wNrolunaN Cl Loan AAGEN ❑ RDIXA4AGBIGY INDIVIDUAL ❑ CWNIKAGENC! i CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA : 6 TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 gROCESDR ✓Box if INDIAN EPA 10 # R M TATSNI ) ❑ TIO 1 GAS STATION ❑3 FARM OTHER IRETRUS LANDIS Dr ❑ AT THIS SITE, Llf� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAf.1E ST.FIRST) ( HONE M WIT AREA OQE� DAYS: N E(LAS RST) l`k ' ?HONE pM=1TH AREA ODE/ NIGHTS: NAME(LASE FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LA ,FIRST) L - PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS Box to ind"- ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY Q INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION ^ `�c :TN� MAILING or STREET ADDRESS - -to inEioete ❑ PARTNERSHIP CISTATE-AGENCY ,�ryN'�//�� `` CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY 4 Q I VV 1 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE S-7LAJ coo, IV. LEGAL NOTIFICATION AND BILLING ADDRESS 4J'•(�f'rJj_ 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 M JURISDICTION R AGENCY S FACILITY ID R R o/TANKS at SITE Eff] =_ = 101011 li= l0lolo CURRENT LOCAL AGENCY FACIEID� wMI0 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER LE�J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT g# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED O 49 -3 1 YES [:] NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:(' S 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. 41 'FA (3-2-88) C � DATA PROCESSING COPY