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STATE OF CALIFORNIA ,, WATER RESOURCES CONTROL BOARD v ORM A. UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE A, C9L,xO tM,P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 2115"CHANGE OF INFORMATION7 PEW TLY�J CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT 1:14 AMENDED PERMIT [_]6 TEMPORARY SITE CLOSURE �I�' J I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION MAILING or STREET A00R SS ADDRESS NEAREST CROSS STREET ✓11110 iM¢aW ❑ PARTNERSHIP [ISTATE AGENCY 11 Ar _r)?6 ✓ Rax to intlicate ❑ PARTNERSHIP ❑ RPOBATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY E ❑ CORPORATION ❑ LOCAL -AGENCY INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE #. WITH AREA CODE STATE CA 9 n/ TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID # RECEIPT# # al TANKb 1 GAS STATION ❑ 3 FARM ❑ ❑ 5 OTHER TTRUSTVLANDS o ❑ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS'. NAME (LAST, FIRST) PHONE # WITH AREA CODE C Z 47fr-vis NIGHTS: NAME ILAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (IAST, FIRST) PHONE # WITH AREA CODE 145 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME. l CARE OF ADDRESS INFORMATION MAILING or STREET A00R SS JMMOL'j CURRENT LOCAL ENCY FA ILITY ID # ❑ CCppRPORATION ClLOCAL-AGENCY❑ FEDERAL -AGENCY MAILING or STREET ADDRESS ✓ Rax to intlicate ❑ PARTNERSHIP ❑ STATE -AGENCY STATE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY Q IR—NI&WDUAL ❑ COUNTY -AGENCY CENSUS TRACT # CITY NAME STATE ZIP CODE P ONE #, WITH AREA CODE n/ C71 5nt3 2f79' -,q 3 III, TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION MAILING or STREET A00R SS 1/ 60. to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CURRENT LOCAL ENCY FA ILITY ID # ❑ CCppRPORATION ClLOCAL-AGENCY❑ FEDERAL -AGENCY APPROVED BY NAME PHONE # WITH AREA CODE I17�iNDIVIDUAL Cl COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE PERMIT EXPIRATION DATE LOCA51N/ ODE (/x111 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. V 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 A nnwl w^mlu v I ICC ^mI V COUNTY # JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE 6 CURRENT LOCAL ENCY FA ILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA51N/ ODE (/x111 CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES E] NO E] DATE FILED 3/ 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 ONLY. FORM A (3-2-88) DATA PROCESSING COPY rwi -7 10 hl MN W