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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM = " SITE A FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONLY CLOSED SITE IV ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE q J CA 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME ^ CARE OF ADDRESS INFORMATION S 'a ADDRESS _ ,�//��A NEAREST CROSS STREET I/Box WMae 0 PARTNERSHIP 0 STATEAGENCY /�rA 7 i�- 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY [1INDNIDUAL 0 COUNTY AGENCY CITU NAME STATE CZIP CODE SITE PHONE p,y(ITH CODE A J TYPE OF BUSINESS: 0 2 DISTRIBUTOR [:]4 CESSOR ✓Box d INDIAN EPA IDN RESERVATION or of TANK'% I GAS STATION 3 FAflM 5 OTHER TRUST LANDS ❑ AT THIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE M f -Ti/-vS -" �3>- Y7o� NIGHTS: NAME(LAST,(PST) f PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE �� PHONE a,�H ARE,_CODE w O III. TANK OWNER INFORMATION & DRESS — (MUST BE COMPLETED) Q/ Op3 [7/ NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.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 AM IN E 8 GN URE) DATE 2fi1 cam_ I LOCAL AGENCY USE ONLY — — — -- COUNTY% JURISDICTION If AGENCY% FACILITY ID If %o/TANKS at SITE 39 oa V I to 14 0 CURRENT LOAAL AGENCY FACILITY ID 11 APPROVED BY NAME PN NE Jr WITH AREA CODE s )- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE I CENSUS TRACT% SUPERVISqOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED A Z YES NO 1:1 CHECK% PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Al BY: THIS FORM MUST BE ACCOMPANIED BY AT LEP%T(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, ORM A(3-2-88) q q �'� DATA PROCESSING COPY �'