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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION c_ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ER'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION `e J /� ADDRESS NEAREST CROSS STREET v,ON wievek ❑ PM105HP Cl UATEAWO DoL .� C 00 Ix ila 00 �_ 0 PEEIVL AGDIC/ CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE D v CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID a RESERVATION or Nof SI ❑ I GAS STATION ❑3 FARM IVs ❑ 5 OTHER TRUST LANDS ❑ AT THISHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 619- 5 NIGHT N ( ST,F STI PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE em- 70 7 -7 33 11. PROPERTY WNER INFORMATION 8 ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION L4 ;I MAILING or S EET ADDRESS ✓Box Io ietlicale ❑ PARTNERSHIP ❑ STATE-AGENCY �,� 0 CORPORATION 0 LOCAL-AGENCY 11FEDERAL-AGENCY60 J f?l /S� e ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP DE PHONE N.WITH AREA CODE !-u 'e- ns z _ y¢/ - /s7 Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION e Ci 5 MAILING or STREET ADDRESS ✓Box mintlicwe 0 PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 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 BILLING: I. ❑ 11.V 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY K LTTYtO.1 M of TANKS N SITE '• y C T LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE N WITH AREA CODE oh�l U PERMIT NUMBERAL DATE PERMIT EXPIRATION DATE E E CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FlLED DATE FILED z . S-0 2 YES NO PERMIT AYOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN C 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(3-268)