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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD / r FORM `A". UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° IC. S COMPLETE THIS FORM FOR EACH FACILITY/SITE10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F& ONE ITEM ❑ 2 INTERIM PERMIT 1:14 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 0 CD 1 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W FACILITY/SITE�A�"E CARE°�F ADDRESS INFO MATION VO N eerls V Atj Vl e�5, ADDRESS .I�/ NEAREST CRO STREET ✓Bw 0W.W Cl PARTNERSHIP El STATE-AGENCY 2 V 5l� / e (/ ❑ INOIVI ¶ON El �LOChAGENCY 13 FEDERAL AGENCY CITY NAME STATE Z ODE SITE PHONE#,WITH AREA CODE C-sc-.l1o�l CA 53� 2d�- g-/6/0 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # ❑ ❑ rl/ RESERVATION or M of HIS SITE / I GAS STATION 3FARM L1450THER TRUST LANDS ❑ OIN e� AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRJ ST) PHONE#WITH AREA CODE itleach /J La'i-8 S- /0 (lk1 NIGHTS: NAME(LAST,FAST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIR3T) PHONE#WITH AREA CODE P,ectdsJ -140 UKN II. PROPERTY dWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAM / CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box m indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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 N JURISDICTION k AGENCY# FACILITY ID R W of TANKS at SITE ® = = 10 102 Z 11 1 woe 11 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE#WITH AREA CODE S PER MI NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT NC DE CENSUS TRACT# SUPERVI3 �TRICT CODE BUSINESS PLAN FILED ❑ DATE FILED r_1 YES NO (/ C CHECK♦ PERMIT AMOUNT SURCHARGE 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 0 LY. FORMA(3-2-88) `� DATA PROCESSING COPY -�,/