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STATE OF CALIFORNIq WATER RESOURCES CONTRORL OARD fyl E°0;'y�o WP. ; 7 FORM `A': y � UNDERGROUND STORAGE TANK PROGRAM W. C W. SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION _ -fir-7 COMPLETE THIS FORM FOR EACH FACILITY/SITE C.44.,FORN P MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 01 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAGE-7r C,NEARES/T` CARE OF� �S INFORMATION MAILIN��Gaa or STREET ADDRESS % ADDRESS ✓Box to indicate L( CORPORATION CROSS STREET��✓ Biy�'fo indicate ❑ PARTNERSHIP ElSTATE-AGENCY Y FACIL CURRENT LOCAL AGENCY ID # El CORPORATION ElLOCAL-AGENCY❑ FEDERAL -AGENCY o(/ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ COUNTY -AGENCY CITY N E ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE SITE P ONE #, WITH AREA CODE ro/)/ Gz CA 73Z TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 YROCESSOR -/Box if INDIAN RESERVATION or EPA ID # # of TANK's ❑ 1 GAS STATION [:]3 FARM 5 OTHER TRUST LANDS ❑ Jq CHECK # AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EME GENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST)') Q P ONNE ## WITH AREA CODE DAYS: NAME (LAST, FIRST) PHON ITH AREA CODE /S' /O' - d L�'0 4 A NI S: N E (LAST,R PHONE #WITH AREA CODE S/4 NIGHTS: NA E (LAST, FIRST) S/4 PHONE #WITH AREA CODE C r 11. PROPERTildWNgR INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME _ CARE OF AD RESS INFORMATION /l/ A MAILIN��Gaa or STREET ADDRESS % 'L71 ✓Box to indicate L( CORPORATION ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ LOCAL -AGENCY ElFEDERAL-AGENCY -/Box to indicate El PARTNERSHIP ❑ STATE -AGENCY lolol1l,(--lvb1 It Y FACIL CURRENT LOCAL AGENCY ID # El CORPORATION ElLOCAL-AGENCY❑ FEDERAL -AGENCY o(/ ( ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY N E STAT ZIP CODE Zzz,D 14 PHONE #, W H AREA CODE yds 7 17-- 2,07 III. TANK OWNEWINFORMATION & ADDRESS - (MUST BE COMPLETED) J NAME CARE OF ADDRESS INFORMATION S # of TANKS at SITE [= MAILING or ST EET ADDRESS -/Box to indicate El PARTNERSHIP ❑ STATE -AGENCY lolol1l,(--lvb1 It Y FACIL CURRENT LOCAL AGENCY ID # El CORPORATION ElLOCAL-AGENCY❑ FEDERAL -AGENCY APPROVED BY NAME PHONE # WITH AREA CODE 1 ^ 6J ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME /4STATE ZIP CODE PHONE #, WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE IV. LEGAL NOTIFICATION AND BILLING ADDRESS 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 # JURISDICTION # AGENCY # FACILITY ID# # of TANKS at SITE [= I' lolol1l,(--lvb1 It Y FACIL CURRENT LOCAL AGENCY ID # APPROVED BY NAME PHONE # WITH AREA CODE 1 cl�.r 3 qr &I/-z'l� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Gz LOCATION CODE CENSUS TRACT # SUP RVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED 6 YES r-1NO 6 CHECK # PERMIT AMO T 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. FORM A (3-2-88) /1 -u (��Q�qL • DATA PROCESSING COPY S