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STATE OF CALIFORNIITK WATER RESOURCES CONTROL BOARD i FORM `A': UNDERGROUND STORAGE TANK PROGRAM =" SITE E� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 P RM NENTLY CLOSED SITE ONE ITEM ❑2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z Im 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) F 1 / RE NA E CARE ADDRESS INFORMATION D ry AOORESS ARE TCROS STREET ✓Box hiMCele F1PARTNERSHIP ❑ SipiEAGENIX O CGRPGRATDN D LOCALAGRxY I]EPAL NGY strY CITY NAME O F �, STATE ZIP CO�E��❑ INONIGIIASITE PH❑ NNEEN#.WITH AFEA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR El d CESMR RESERVATION N EPA ID 0 qS X of TANK's ❑ 1 GAS STATION E] 3 FARM 5 OTHER TRUSTLANOS ❑ �Q AT THIS SITE 03 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) E�E N W/H A EA CODE DAYS: NAME(RST,FIRST) OQ PH^�I WIT AREA CODE RIGHTS: NAME(LA .FIRST) PHONE p WITH AREA CODE NIG ME(LAST,FIRST) PHONE 4WITH AREA CODE S A Zoq -r' 3 Zo ? - 3 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NA ECARE F L)ARESS INFORMATION MAILIN`or STREET ADORE ✓ Ofx/two 1noicate D PARTNERSHIP D STATE-AGENCY 19 CORPORATION 13 LOCAL-AGENCY FEDERAL-AGENCY INDIVIDUAL D COUNTY-AGENCY CITY NAW IL" •—v STATE ZIP CODE O �0 HONE WITH AREA CODE CA 1 III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE O5 A Q(iESS INFORMATION MAIUNGor.STFEET ADDRESS ✓ oz to indicate D PARTNERSHIP D STATE-AGENCY CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY SLA ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAML ZIPC E PHQN yJITH AREA CODE ' fLASJ[ J^�hV IV. LEGAL NOTIFICATION AND BILLING ADDRESS 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION R AGENCY B FACILITY ID N M of TANKS at SITE 0 3 Z -77 16o lo CURRE T=0 AGENCY FACILITY-ID N AP %V BY NAME PHONE*WITH AREA CODE PERMIT NUMBER L (J� PERM APP 0 ALL DDAATTE� )N,PPtE'`rRMIT EXPIRATION DATE LOCATION CODE CENSUSTqp�AC/J7�N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED EF D �q YES NO ❑ l 8� 1fV CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT IFBY: ITHIS 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 `J FORM A(3-2-88) DATA PROCESSING COPY ,� 5