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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM =" �o Z SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o go t — 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 64-7 PERMANENTLY CLOSED SITE F'J ONE ITEM Z INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CDCD I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) `I OD FACILITYBIT AME CARE OFADDRESSINFCPY- �p (s SeTvlce �i�MON Ro, U t/,z ADDRESS NEAREST GROSS STREET .✓/ bPAule ❑ PMTNERNR ❑ STATE-AGENCY 0 E 4 d K14 D D ` AGI ❑ EDE0. -AGENp CITY NAMES STATE ZIP ODE SITE PHONE a,WITH AREA CODE 134ockfol-i CA �52 `/b 2d4 Y6S-3 z 7 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4PROCESSOR ✓Box it INDIAN EPA IID'N R of TANK'R GAS STATION ❑3 FARM J 5 OTHER TRUST ATION or ❑ L�/�./" AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 0N0l , -Av) 2oq-y6s--3v2 f UKN NICs T,N M ( O FIRST) 2 PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE ((/'/�//��ff IL JIB/ 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME �� A� �� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDR S — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.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.Az 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION If AGENCY R FACILITY ID If If of TANKS M SITE CURRENOT LOC�AGENCY Fi QI ITY ID R APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER SS YYCL////\\ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LEI US TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED lYES NOIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If B THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK P:RART FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION FORM A(3-2-SB) �� DATA PROCESSING COPY .� ;