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,� _ ws:-n,.:-:-u+N�r,.,�..�w-...--'�,i+`'�•'. t ,.�, _. '; � '".` i�.. .��r yj.;a., :�f`"JAH� STATE OF CALIFORNI. _ WATER RESOURCES CONTRG— BOARD 4: FORM 'A'-----. Q„F��ty��. UNDERGROUND STORAGE TANK PROGRAM �"`Y— to SITE ��'� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - P1a At COMPLETE THIS FORM FOR EACH ACILITY/SITE ^4,FTR�P MARK ONLY EW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P RMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) w W FAtILITY/SITE NAM CARE OF ADDRESS INFORMATION cd , ADDRESS T 1:1NEAREST CROSS STR ✓Box to indicate ❑El ElSTATE-AGENCY el)OV S• ❑ CORPORATION LOCALAGENCY ERAL-A NCY ��y�lll INDIVIDUAL ElCOUNTY-AGENCY CIN NAME STATE ZIP CODESITE PHONE#,WITH AREA CODE L 6/Yl CA `�S�Z�I a (Z-7 $01 TYPE/O F.BUSINESS: ❑ p DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID #' / #of TANK's IJ GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTLANDSATION or ❑ r AT THIS SITE 64— EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME ST,FIRST) PHONE#WITH AREAC DE DAYS: NgME(LAST,FIRST) P #WITH AREA CODE NIGHTS: NAME(LA FI ) PHOV#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) P E It WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NA E CARE 0 ADDRESS INFORMATION C)- 1-11AA Of a � C MAILING'7or S EET ADDR`EESS ,/� -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY L—Zt L 1 1 v l � CORPORATION El LOCAL-AGENCY/ — EDANCY 1:1 NIVIDUALElCUNTYAGENCY � 0 CITYN STATE ZIP CODE } ITRCODE � (5V �� /om / l III. TANK OWNER INFO MATION & ADDRESS — (MUST BE COMPLETED) NAME CARED ADDRESS INFORMATION /p ot-t� &)IA MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY D / ElCORPORATION ❑ LOCAL-AGENCY FEENCY C1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAM STAIF ZCODE �� PHONE �ITH AREA ODE IV. LEGAL N IFICATION AND BILLING ADDRESS 3 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 COrnNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE I I I ] EI I I 1010111fly-i-11 0 10 T6_141- CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NE PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE ERMIT XPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 2j D [ YES N04�1 L if CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 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 ONLY. FORMA(3-2-88) tDATA PROCESSING COPY