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STATE OF CALIFORNlioa) WATER RESOURCES CONTROARD FORM 4A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT flE5 CHANGE OF INFORMATION ❑ 7 PEp4A NGNTLY CLOSED SITE ONE ITEM ❑p INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / 51 Z I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I G FACILITYISITE NAME CA E OF ADDRESS INFORMATION w AODRES �Q� � ( � EAREST CROSS STREET JBolbvko ❑ PARTNEPSNP ❑ STATE AGEND 00 'A .. . ZA" ❑ff��AAPCRANON ❑ LOCALAGENCY ❑ FEOEFAL AGEND Au�� L�TINOMOWL ❑ COUNIYAGEND CITY NAhI/✓Vw1E ©l STATE ZIP ODE ITE PHO k WITH AREA CODE CAS CA S��10 o D b TYPE OF USINESS. ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BozdINDIAN EPA ID a 1 GAS STATION ❑3 FARM ❑ 5OTHER TRUSTYLANDS or ❑ FOITANSI ^ AT THIS SITE bl/ EMERGENCY CONTACT PERSON(PRIMARY) EMEF1ENCY CONTACT PERSON(SECONDARY) GAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS.. N ME(LAST.FIRST) PHOsNE WITH AREA CODE HTS: NAME(LAST.FIRST)f PHONE WITH AREA CODE NIGHT1�IAME(LAST,FIRST) PHONES AH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) or //I` NAM CARE OF A DRESS INFORMATION I MAI NO or ST ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY ( RPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMESTATE ZIP COD)��© PHON ITH AR ACODE ILlim Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OFA RESSINFORMATION MAILIN FEET ADDRESS J Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑�O RPORAON El LOCAL-AGENCY ElFEDERAL-AGENCY 18'INDIVIDUALTI ❑ COUNTY-AGENCY CITY NAM STATE ZIP CO PHONE# WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS SS�� S CHECK ONE(1)BOX 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 k JURISDICTION a AGENCY k FACILITY ID If N of TANKS at SITE o 1 to I I = 1 U5 10 CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA FILED Oz 23.8bq15 I YES NO 0 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE pECE1PT• 8 \ 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(3-2-88) �� "' DATA PROCESSING COPY