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STATE OF CALIFORNIf WATER RESOURCES CONTROL FORM `A': _ �` T, UNDERGROUND STORAGE TANK PROGRAM / SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2<CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I a' I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 90 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION WALUD M . W A__U n ADDRESS NEAREST CROSS STREET ✓B"m mull¢ D PAHINERSHP ❑ STATEAGENCY _� ❑ CORPORATION D LOCAL AGENCY D FEDERALAGENCY UAL D COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE ft WITH AREA CODE "—C A CA jS33L,, N�� TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID 4 B of TANKS ❑ I GAS STATION [:] 3 FARM 0b6TREB TRUSTVATIONLANDS or ❑ AJ6 C AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE t UJA-tLiO a X23--233 NIGHTS: NAME(LAS(FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �,tJAd-1,f� �1, Q r MAILING or STR TADDRESS I/Box 1.Ldicate D PARTNERSHIP D STATE-AGENCY D CORP ATION D LOCAL-AGENCY D FEDERAL-AGENCY W V ` IDUAL D COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE �31&cSl3'Z3.3> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME �p CARE OF ADDRESS INFORMATION r�1 MAILING or STREET ADDRESS ✓Dox to indicate D PARTNERSHIP D STATEAGENCY D CORPORATION D LOCAL-AGENCY D FEDERALAGENCY D INDIVIDUAL Cl COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE p,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 BILLING: I. ❑ IL 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 N JURISDICTION k AGENCY IN FACILITY ID 9 N of TANKS at SITE 3H = = lC? U U CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE W R �J_T PERMIT NUMBER PERMIT APPROVAL,D/ATE PERMIT EXPIRATION DATE N LOCATION ODE CENSUS TRACT N SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Q 23 1 YES NO CHECK k PERMIT AMOUNT SURCHA GE AMOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(8-2-88) DATA PROCESSING COPY 6