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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM reo SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 ,cc! COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY F—] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"J' ONE,ONLY ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ~ FACkiM1�E NI.IJE r� CAR 604: D 4 S INFORMATION ADD``RRE ��T�!1y��''MAA^,�',[(�j / N ,ST QRROSS STREET ✓BW W Mi;* ❑ PARTNERSHIP ❑ STATE AGEN 11 00Cl LOCAL AGENCY NCY ❑ INGMDAL� ❑ COUNTY AGEN L CITY NAME STATE ZIP ODE ITE PHO E N,WITH AR CODE Srn1.lc�� CA cS'wl oq V4 S TYPE OF BUSINESS: 2DISTRIBUTOR ROCESSOR ✓Boxif INDIAN EPA ID x If of TANK's /) ❑ 1 GAB STATION ❑ 3 FA flM S OTHER RESERLANDSVATION or ❑ �,/( AT HIS SITE 6(l EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DA NAME(LAST IRST) , PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 6 �3g1A S14 NIGH S. NAIfE(LAS .FfRST) ONE#WITH AREA CODE NI T : NAME(LAST.FIRST) PHON WITH AREA CODE �Tft o 1.� r9 A lk 11. PROPERTY OWPOR INFORMATION & ADDRESS — (MUST BE COMPLETED) NA D Few' /1 CARE OF AR ESS INFORMATION MAIL( or STRE ✓Box to indiCate Cl PARTNERSHIP ❑ STATE AGENCY FCSDDR SS ❑ CORPORATION ❑ LOCAL-AGENCY F ERAL- GENCY �V,/1• J l 11 INDIVIDUAL ❑ COUNTY-AGENCY CITY STATE ZIP CII.�'Za� HONE I(H AREA $,)D�u?p III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) Z 'r/ NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax m indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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# JURISDICTION M AGENCY# FACILITY ID# #of TANKS at SITE [Eil 10101 / 1 1 if I J, V I I p I o 106 CUR NT�AL A�i CY FACILITY ID# APRIipVAPB N ME PHONE N WITH AREA CODE T I/L PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EX (RATION DATE LOCATION CODE CENSUS TRACT k SUPERVISOR-018 ICT CODE BUSINESS PIAN FILED DATE FILED •4� L YES NOL- . CHECK# PERMIT AMOUNT SURCHAR E 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. FORMA 13-2-88) � DATA PROCESSING COPY