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STATE OF CALIFORNIP WATER RESOURCESyEP�u"� T"F CONTROARD FORM `A': m UNDERGROUND STORAGE TANK PROGRAM Mo SITEF(j? FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE C,�IFO RN P MARK ONLY f NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PE Y CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O/ 1e I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACT SITE N ME Q CARE OF RESS INFORMATION ADD ESS �^ N REST CROSS STREET ✓ ortoindicate ❑ PARTNERSHIP ❑ STATE-AGENCY CM 9 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY (N 00 ll ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME tSTATE Z7CrZ—C/ 'ODE IT D H AR`COD `C ! ] TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID #RESEC! ❑ ❑ ❑ TRUST LANDS ATION�r ❑ #of HIS SITE 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PH NE#WITH AREA CODE f/ -•7?77 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHO14E#WITH AREA CODE �E �rs� Z3- 7 5 /4 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) N Er CARE OF A DRESS INFORMATION A a'a 0 MAILING or � STET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ElSTATE-AGENCY }' En CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY ✓6 `•Zf gV ❑ INDIVIDUAL ❑ COUNTY-AGENCY a CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE (/s`9 7 s LA I11. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF AD ESS INFORMATI N 1-4 t§71 MAILING or STREET ADDRESS ✓$ox to indicate ElPARTN SHIP LlSTATE- ENCY „A lob p�CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY 'tel V ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It, ITH AREA CODE 11y- o IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ if. ❑ 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 EPERMITNUMIFER JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE { AGENCY FACILITY IDS APPRO ED BY NAME PHONE#WITH AREA CODE z 1 P� PERMIT PPROV L DATE PERMIT EXPIRATION DATE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILYES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: NONE ;RM HIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON A(3-2-88) DATA PROCESSING COPY f.