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STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD a"s FORM A: UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' to C, COMPLETE THIS FORM FOR EACH FACILITY/SITE I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 FBM&NENTLY CLOSED SITE I"L ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE l c I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE Np ME CARE OF ADDRESS INFORMATION uJl Gr Z ADDRESS IFNEAREST CROSS, ✓Bmtandole ❑ PARTNERSHIP ❑ STATEFIIO' -AG O r 1 I / ❑ CORPCNAPON ❑ LOCAL AGENCY ❑ FEDEMLAGENCI L T 1 LZ, ❑ INDnIDUN ❑ CWNn-AGENCr CITY NAME STATE ZIP CODE I SITE PHONE N.WITH AREA CODE ,srfoc A- N CA 1209-?311 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N ESEIf of TANK' [71 GASSTATION F-] 3 FARM OTHER TRUSTVLAND$ATION Gr ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE detNiacr—k, nb 1-15-31 N NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE uKN ukN 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME As T CARE OF ADDRESS INFORMATION Sam e MAILING or STREET ADDRESS -/Ed.to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sarre_ A _L MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 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. ❑ 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 R JURISDICTION N AGENCY R FACILITY ID R N of TANKS at SITE d 10 z 10 12 bl I(D 10 10 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE U PERM NNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED I YES [j NO 11Gff CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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. RM A(32 88) — tiII/ DATA PROCESSING COPY �../ .