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STATE OF CALIFORNIA- WATER RESOURCES CONTROMBOARD "s FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE X FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;`^��•oap`" COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT P21 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N I'V FACILITY/SITE NAME CARE OF ADDRESS INFORMATION A ADDRESS /� /J /� /� ,� NEAREST CROSS STREET ✓ bv4imA ❑ PAATNSWIP ❑ STA7EAGE4CY 3 /33 ad.� /A 6{ Q CO 60AA70N o LOCAs-AGENCY ❑ FEWL.AGDCY Nw ❑ INp IWAL ❑ CWNN AGENCY CITY NAM STATE ZIP CODE /SITE PH NE k WITH AREA CODE G v CA S Z G 9 4S 1 -ba�6 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑�4 PROCESSOR ✓BOx it INDIAN EPA ID Dp# ❑ 7 GAS STATION ❑ 3 FARM Iv l 5 OTHER TRUST ION or ❑ 69u 6 67 b 63 AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE cxlt n� a6o z� r- 86 NIGHTS'. NAME(LAST FIRST( PHONE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE QUA 2 `t'r ( - r� Zc t-v� ��' II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to i,dIcale ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 5/A MAILING or STREET ADDRESS ✓Box Lo,rd,oale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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. 11. ❑ 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 K JURISDICTION W AGENCY41 FACILITY ID N S of TANKS at SITE D —7y Ov03 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY AME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCA��ODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 4/ YES NO `i l� I� OK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-68) - DATA PROCESSING COPY