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a STATE OF CALIFORNIA WATER RESOURCES CONTRG.,.0JOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - : Z COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SED SITE F-a ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT K6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION PaLry' Lis Ayxt ADDRESS IJ //' NEAREST CROSS STREET �� ✓Box lDrdC le ❑ PARTNOMP ❑ STATE.AGIDO /V, S (N Q' .S�lI✓l Lvr Y1.et 6e ❑ coVMTION ❑ LOCAL-AGM ❑ R DM&AGIDO ❑ NDIYIDIIAI ❑ C=M-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE S�O U�/1 `�'t � CA 129 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR I ✓Box 0 INDIAN EPA ID # TAT f TANK'S1 GAS STATION ❑3 FARM OTHER TRUSTYLANOSATION or E] THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 6 - a NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION r ro �^ '� S MAILIN STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY //^^ ❑ C90ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY t 9t 3 DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE C Z520 7 III. TANK OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION r MAILING or STREET ADDRESS v ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLIN : I. ❑ ILK Ill.EJ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL GE,IS TRUE AND CORR APPLICANTS NAME(PRINTED&SIGNATURE) DATE . LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS st SIJE ® O11131 - DB o7T�4 CURRE LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA C PERMI NUMBER PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED3 YES NO ❑ ` 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.. FORM A(3-2-88) f iDATA PROCESSING COPY