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STATE OF CALIFORNIA WATER RESOURCES CONTRUL BOARD FORM 4A4: UNDERGROUND STORAGE TANK PROGRAM V m� SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �.' COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IVS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) to FACILITY/SITE NAME CARE OF ADDRESS INFORMATION u owx amuck) kt o2 DO ADDRESS nn�� NEAREST CROSS STREET 0 f�o'dolNH! D lMIT111 0 0 STATE AE0.LL� 00 ZZI W INOL� YA/ s D MpWM D MMK*NLY CD CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE W Sok o Jul CA 2 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑/PROCESSOR ✓Box if INDIAN EPA ID p E] I GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTT LANDS or ❑ S of TANK'4 AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST.FIRST? PHONE 4 WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS NAME(LAST.FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE 4 WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION N MAILING a STREET ADDRESS ✓Box b iw,we 0 PARTNERSHIP D STATE-AGENCY QNB,. ��p� 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY JOo 0 INDIVIDUAL 0 COUNTY-AGENCY CITY HAW STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) )� NAME CARE OF AQDRESS INFORMATION c lke rTa/aeol_ MAILING m STgEET ADDRESS I/Box to mdicete 0 PARTNERSHIP 0 STATE-AGENCY 0CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY C INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE S-foc(c+0 r.) Ci) ..Sad aory - &S� IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ it. ❑ 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 COUNTYII JURISDICTION S AGENCY R FACILITY ID S N of TANKS at SITE ® = I I I 1 161 OURRIENTLOCALAAOENCYFACILITYIDI APPROVED BY NAME PHONE 4 WITH AREA CODE e PERMITNUMBER ----- PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT F SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDDATE FILED Q .2 3 32 S— YES NO � 1112 9() CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 4 BY: THI A FORM MUST BE ACCOMPANIED BY AT LEA I OR MORE TANK PERMIT FORM 'B'APPLICATION(S), SS THIS IS A CHANGE OF SITE INFORMATION ONLY.