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�l c STATE OF CALIFORNIA WATER RESOURCES CONTROL'80ARD Vis` "'`" FORM A': po UNDERGROUND STORAGE TANK PROGRAM SITEJL FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC HF ILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION NENTLYCLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I o FAO ITY/ NAME / L CARE OF AD SS INFORMATION ADDRESS `dT1�Y-N/-.Y `TL�f^B- p�-� NEA ST CFbSS STREET ,.✓, oiMrale ❑ PARTNERSHIP ❑ STATE AGENCY N GOHFORATION ❑ LOCAL AGENCY ❑ FED ERALAGENCY �I ❑ ROMDUAL ❑ COUNTY AGENCY co CITY STATE ZIP CODE SITE P NE# WITH AREA CODE W D Al —nN CA S Zor' TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bu it INDIAN EPA ID X #01 TANK' RESEX ❑ I GAS STATION [:] 3 FARM �THER TTRUSTYATION LANDS D ❑ AT THIS SITE B 4 EMERGENCY CONTACT PERSON(PRIMARY) EMERG NCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRSTP ONE#WITH AREA CODE DAYS'. NAM (7 AST,FIRST) PHONE#WITH AREA CODE ( NIGHTS. NAME( ST,FIRST) PHONE X WITH AREA CODE NIGHTS.- NiE(LAST.FIRST) PHO p WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF A ESS INFORMATION MAILINGorSTET DDR to lntlicate ❑ PARTNERSHIP 11 STATE-AGENCY CORPORATION EILOCAL-AGENCY 11FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAAE ✓1>✓W X� STATE ZIP CODE PHONE X.WITH AREA CODE �b i ZO D III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE D KESS INFORMATION 15 A MAIL IN o S li ADDRES etointlicate ❑ PARTNERSHIP ❑ STATE-AGENCY �1 CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY / \ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CI E STATE ZIP C E HONE .WITH ARE CS t p— q - Soo IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. V111. ❑ 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 CO�UNTTYY# JURISDICTION# AGENCY# FACILITY ID# #o1 TANKS at SITE IS -�I I = i Df- 1�1310 O CURRENT LOCAL AGENCY FACILITY ID# APP VED BY NAME PHONE X WITH AREA CODE ICHI D PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRI ' SUPERVI R-DISSTCT CODE BUSINESS PLAN FILED DATA FIL 7/ Z YES NO CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X /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. FORMA(3-2-88) �/ DATA PROCESSING COPY J,`