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STATE OF CALIFORNIA WATER RESOURCES CONTROBOARD J 5" FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u � " SITE (_,,, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ITY/SITE ""`°"-=�� y MARK ONLY F-1I NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE Z4 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6a a0 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) w cG FACILITY/SITE NAME CARE OF ADDRESS INFORMATION f 0, S /y ADDRESS NEAREST CROSS STREET ✓Rxtorxtmle 0 PARTNERSHIP 0 STATE AGENCY 7 v //� O I TION ElLOCCAL AGENCY ❑ FEDERAL AGENCY O NOIVIOUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE 9,WITH AREA CODE <f 5 lord CA Sia D 1 .2o 9 -k 32? TYPE OF BUSINESS: ❑ p RIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a N of TANK's ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER RRUSTYU\NDS ION o El 11AT THIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE O- Liu/zo?D9-6'3b 3 �+ NIGHTS: NAME(LAST FIRST) PHONE p WITH AREA CODE NIGHTS'. NAME(IAST.FIRST) PHONE N WITH AREA CODE c5 a w--' II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION u Mlles-f MAILING or STREET ADDRESS ✓Box tt ndIcate 0 PARTNERSHIP 0 STATEAGENCY 0 DBAPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE ' tin 9.5'3-;7v III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS FCHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY M FACILITY ID It It of TANKS at SITE q3 CURR OC Y FACILITY ID# APPROVED BY NAME PHONE a WITH AREA CODE a PERMIT NUMBER PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 YES [j NO CHECK# PERMIT AMOUNT SUR CHARGE AMOUNT FEE CODE RECEIPT0 BY:��al 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) DATA PROCESSING COPY 3 `� ab