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STATE OF CALIFORNI)r' WATER RESOURCES CONTROL'V'OARD 1 FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE Ej FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ru COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMAN NTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 10 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FA LIN/SITE CAR SS OFA DRE SS INFORMATION Tin.v N Iv ADDRESS NEA EST CROSS STREET ✓Rx iriPxRie ❑ PARTNERSHIP ❑ STATE AGENLY 3�75� ElCORPORATION 13LOCALAGENC4 ❑ FEDERAL GENCY ❑ INDIv1GML Cl COUNTYAGENL Iff CIN NAME ✓ "/� STATE DECODE SITE PHONE p,WITH AREA CODE CA TYPE OF BUSINESV ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p •/ N of TANK's RESE1 GASSTATION [:] 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION o ❑ A AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS. NAM (LAST,FIRST) RHOyyE p WITH AREA CODE 13 NIGHTS. NAME(LAST,FWfI PHONE p WITH AREA CODE� NIGHTS: NAME(LAST,FIRST) PH WITH AREA CODE S I� S /� S II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 's N M MAILING.,'STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ ERAL AGENCY U, ❑ INDIVIDUAL ❑ COUNTY-AGENCY GI NAME STATE ZIP CODE PHONE A,WITH AREA CODE GA I �S 6 III. TANK OV60ER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ^ _ / CARE OF A)RESS INFORMATION i045R&4144 J0_ MAILING S T ADDRESS ✓Be.to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ ERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STAT ZIP CODE PHONE .WITH AREA CODE C. � C I 7Z IV. LEGAL NOT ATION 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY u FACILITY ID N N of TANKS BI SITE m = = 16161l DD D CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DIJTRICT CODE BUSINESS PLAN FI[:]LED OAT ILE 1�016 YES NO CHECKN "PERMIT AMOUNT SURCHA GE AMOUNT FEE CODE RECEIPT X BY: TH 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 (3-2-88) - +-� DATA PROCESSING COPY \