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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM Y'o z S!T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ic C COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 10�5 CHANGE OF INFORMATION ❑g7 PERMANENTLY CLOSED SITE F 4 ONE ITEM ❑ B INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE J cNn) 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CD FACILITY/SITE NACARE OF ADDRESS INFORMATION ME ' ADDRESS NEAREST CROSS STREET ✓ to+qo8 ❑ PARTNEPBIIP ❑ STATEAW* 'S, �h ❑ NNPG 1011 ❑ I0C&AQDa ❑ F90k ASEN Y pMOM ❑ c0uhv-T,Encr CITU NAME 0 CI / STATE 21P CODE SITE PHONE p,WITH A?CODE 71 TYPE OF BUSINESS: ❑ p DISTRIBUTOR 0 4 PROCESSOR ✓Box if INDIAN EPA 110,n /� N of TANK'ESEVATIONa ❑ 1 GAS STATION ❑ 3 FARM A OTHER TRUST LANDS cr ❑ Y W Yom— AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAV NAMELAS�ST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE -91n NIGHTSNAME(LAST, IRST) PHONE N WITH AREA CODE NIGHTS: NAME(LOST,FIRST) PHONE N WITH AREA CODE S01_11�— II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ o.to indicate Cl PARTNERSHIP C STATE-AGENCY Z� CORPORATION ❑ LOCAL-AGENCY ClFEDERAL-AGENCY J 7 ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE x.WITH AREA CODE 41&1 ) q4r N 1 DOAa, t.4 III. TANK OWNER INMIRMATION & ADDRESS — (MUST BEC MPLETED) NAME y CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ('1 !/ ✓80x to,mcalg ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL.AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CNECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. v II. ❑ 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION N AGENCY* FACILITY ID A N of TANKS at SITE ml 60 it 5 g O CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE N WITH AREA CODE PERMIT MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED �L /y^� © 1 YES [] NO TA41 U CHECK t PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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. I FORMA 132-801 1 1 _ t1T'I,IIvII � DATA PROCESSING COPY �_