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STATE OF CALIFORNIO WATER RESOURCES CONTRamnb Cgs FORM 'A': NOV 21 19 UNDERGROUND STORAGE TANK PROGRAM --� SITE lAx FACILITY/SITE, INFORMATION and/or PERMIT APPWq AzJ7,k(aft Icy COMPLETE THIS FORM FOR EACH FACILITY/SITE PERMIT i SEi2ViC ES FORK P MARK ONLY EW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMAN SED SITE ONE ITEM ■2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION G ADD ESS NEA EST CROSS STREET ,,�✓, qFto indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 2 , �^ t�Y'CARPORAL ❑ COUNTY-AG CY ❑ FEDERAL-AGENCY 1.J ❑❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY JNAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE TYPE OF BUSINESS: p DISTRIBUTOR 4 PROCESSOR RESERVATION or ❑ EPA ID # #of TANK's iASSTATION Ej 3 FARM �5 OTHER TRUST LANDS ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FI T) PHONE#WITH AREA CODE NIGHT : NAME(LAST,FIRST) PHONE#WITH AREA CODE -2 ;3n f� 3 n 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COM LETE ) �((( NAME CARE ADDRESS INFORMATION MAILW or STRf4T ADDRESS �✓Bye to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY vrey Z:�1+' CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY Px ;�� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE - III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE F ADDRESS INFORMATION 1 � N MAILING or A;ADDRESS ✓ o indicate ❑ PARTNERSHIP ❑ STATE-AGENCY D s CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODEL4:1; #, ITH AREA CODE f(SCLC IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 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) �? �j,�i DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE ® ,�- 1 ,3 15Flob 1 v I il CURRENT nL AGENCY FACILITY ID# APPLIOYED BY NA E PHONE#WITH AREA CODE ��sov ttilk PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EX IRATION DATE I LOCATION CODE CENSUS TRACT# SUPERVI -DISTRICT CODE BUSINESS PLAN FILED DATE ILED YES NOj2( CHECK# PERMIT AMOUNT SURCHARGE MOUNT FEE CODE RECEIPT# BY: i THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UN LE THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) 40 C DATA PROCESSING COPY )