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STATE OF CALIFORNrm WATER RESOURCES CONTROL BOARD l` FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o Z SITE /n J FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; to C / COMPLETE THIS FORM FOR EACH FACILITY/SITE ""OP"'� MARK ONLY 1 NEW PERMIT F-1 3 RENEWAL PERMIT [-] 5 CHANGE OF INFORMATION 7P LY CLOSEDSITE ONE ITEM 2INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE a/7 I. FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) FACILRY/SITENAME _ CARE ADDRESS INFORMATION 4. 0.51,10 el ia✓ it ADDRESS NEAREST CROSS STREET ✓Amb irAule ❑PTIER5HIP D SI,11E1GENO �/ D C0.MflON LOCAL AM' D REM AGENCY ,!/V I Al D INOYIOUAL D CDUNIYACENCY CITY NAME STATE ZIP DE SITE PV ONE N,WITH AREA CODE d( CA Tr2lv6 3$l-?l7 TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 P SSOR E Eox R INDIAN N EPA 10 a nj� E of TANK's �) 1 GASSTATION 3FARM GTHER TRUST LANDS A ATTHISSITE 4— EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DXAME NAME(LAST,FIRST) P NE N WITH AREA CODE - 11.0A 51A NIGHTS: WAME(LA ,FIRST) PHONE p WITH AREA ODE NIGHTS: NAME(LAST,FIRST) P ONE N WITH AREA CODE rb*-.URflO 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMECARED TDRESS INFORMATION \ A11A M G oj$7iREET ADDRESS ✓Box to indicate D SA'RTNERSHIP D STATE-AGENCY D CORPORATION IRM LOCAL-AGENCY D FEDERAL-AGENCY S x V D INDIVIDUAL D COUNTY-AGENCY CITY NAME v STATE ZIP CODE PHOK7Z AREA CODE 6 D 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME u CARE OF ADDRESS INFORMATION �Iia MAR-INCS Im STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP D STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. E] II. III.El THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY p JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE a` l = = 1 bb D b 1 It- CURRENT I.00AL AGENCY FACILITY IDN APPFIOVEDBY NAM �7 PHONE p WITH AREA CODE 4 PERMIT NUMBERPERMIT APPR ALDA ERMI ZPIRATION DATE 74 1 LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED ATE LED O Z b VES NO12/ "ECKIf PERMIT AMOUNT SUReNkRGf 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. DRM A(3-288) ^ DATA PROCESSING COPY