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STATE OF CALIFORNIA-- WATER RESOURCESCONTROovitJARD FORM 'A': ° UNDERGROUND STORAGE TANK PROGRAM =°° o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 791 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESSIN ORMATION S e ', N "' ADDRESS NEAREST CR SS STREET ✓Botndrae D PANTNOW D STATE- AGENCY D CIWORATION Cl LOCAL AGENCY Cl FEDERALAGENCYf-AD INWa* D WMTY AGENCY CITY NAME SfAft ZIP CODE SITE PHONE N,WITH AREA CODE 1oj_j CA 116 9 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N RESERVATION or N of TANKS ❑ 1 GASBTATION ❑3 FARM ❑ 5 OTHER TRUST IANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE 0 ! 165, NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(UST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicale D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY Cl 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(T)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. it. ❑ 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 B JURISDICTION M AGENCY M FACILITY ID Al M of TANKS at SITE 39 y El 1 13 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE F WITH AREA CODE jqAm-;?1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LO^CATION CODE CENSUS TRACT P SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED C] DAT/EEjj/I`/LE YES NO 1116 /n / CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y Yr IS 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 ON(lln ` ^ FORM AJ3-2-88)