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STATE OF CALIFORNIA%-� WATER RESOURCESCONTROL�ARD ^'"A FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N a I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) -.4 A FACILITY/SITE NAME MOP-�-TA I9) 5 CARE OF ADDRESS INFORMATION ADDRESS //�+ {�-J//�} �` LZ NEAREST RROOSSSS SSSTTRREEEET/ .✓�IaiMiwh P/HTNEINIP ❑ STATE AGENCY `e' C• � A/'^— / '/ ' _ 0 INO DWLON ❑ COLUI �p GENLY ❑ ROEML-RGENCY CITY NAME STATE ZIP CODE SITE PHONE M.WITH AREA CODE SZDGkTd� CA q�zaG 209-9�f3 7,66 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID x 1 GAS STATION ❑3 FARM ❑ 5 OTHER TTRUSTT LANDS SERVATION or ❑ AT THIS SITE 4 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE k WITH AREA CODE .A K 209 -7,668 MORl7 1- 209 _ ,q(-7f-7S-c/6 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LA T,FIRST) PHONE B WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION A10947W20S MAILING or STREET ADDRESSox to In'icate PARTNERSHIP ElSTATE-AGENCY � CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY fX INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME K1l STA7f - ZIP CODEPH ONE p,WITH OA CODE �� 2 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) 2!'/y NAME ', CARE OF ADDRESS INFORMATION cT� L MAILING or STREET ADDRESS ox to in0icale ARTNERSHIP ❑ STATEAGENCY CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE IE 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. V11. ❑ 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 M JURISDICTION M AGENCY R FACILITY IDM Rol TANKS at SITE ml 10101 /TK[al 1 v v CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE M WITH AREA CODE M e)a-fI SS I GvieS PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE i-2 2 LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PUN NFRED NO ❑ DATE FILED CHECKII PERMIT AMOUNT SURCHARGE AMOUNT AAMOUUNTT FEE CODE RECEIPT M 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. 1 FORM A(3-2-BBI \\V1p\\11111 �1- DATA PROCESSING COPY +�