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STATE OF CALIFORNIA WATER RESOURCES CONTROL oOARD A; FORM `A': m UNDERGROUND STORAGE TANK PROGRAM =� p SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION it COMPLETE THIS FORM FOR EACH FACILITY/SITE Cy C,pppN�P MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM Fp�,NTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE l v 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION `A"7 ADDRESS NEAREST CROSS STREET ✓Box to Weale Cl PARTNERSHIP ❑ STATE-AGENCY � I ❑ CORPORATION E] LOCAL-AGENCY ElFEDERAL-AGENCY❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA iT OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a of TANK' RESERVATION or N s GAS STATION ❑ 3 FARM ❑ 5 OTHER 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 N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE I ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME /J CARE OF ADDRESS INFORMATION 1G2,Q,eVvIj C� ons MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY C 1 (\ ❑ CORPORATION 13LOCAL-AGENCY ElFEDERAL-AGENCY VN r ✓� K S r P� J(/l r /� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME Yt/I V I Q STATE�� ZIP�5 �� PHONE WITH AREA COD/_ % IV. LEGAL NOTIFICATION AND BILLING ADDRESS r/ 9Z9 /V, 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 S JURISDICTION N AGENCY N FACILITY ID S #of TANKS at SITE r-17/ DuFT� 35 Lo � c� CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME _ / PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE /D- g' LOCATI N DE CENSUS TRACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 2 YES ❑ NO ❑ Z/r�� CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ONL . FORM A(3-2-88)