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STATE OF CALIFORNI.... WATER RESOURCES CONTRO. SOARD "` { FORM `A': V UNDERGROUND STORAGE TANK PROGRAM SITE / /FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' . 1 v COMPLETE THIS FORM FOR EA FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ T PER TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURELill I. FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) N O7 FACILITY/SRE NAME CARE OF ADDRESS INFORMATION ick, A S v-e__ olu ADDRESS NEAREST CROSS STREET ✓Bmb- ❑ PARTNERSHIP ❑ SPATE ISM '7 2 a 0 S 4 L 1�IeA po T� o f o RBFALL.AG CITY NAMEI��— ) —v'– ,STATE ZIPCODE SITE PHONE pWITH EA CODE L co ZVI TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 PROCESSOR _/S3 iI INDIAN EPA ID* E OI TANK'* ❑ I GASSTATION ❑ 3 FARM OTHEfl TRUSTLANDS ATION OR ❑ ATTHISSRE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE N WITH AREA COD DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE A- n/ Zo -I Z-0 NIGHTS: NAME(LAST IRST) PHONEp WITH AREACOD NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE o _ 3-26 II. PROPERTY NER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION MAILING toI a ET ADORESV �� ✓Box to indicate 13 PARTNERSHIP 13STATE-AGENCY V ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME 50 STATE - ZIP CODE PHONE p,WITH AREA CODE - III. TANK OWNER IN RMATION & ADDRESS — (MUST BECOMPLETED) NAME CARE OF ADDRESS INFORMATION M K MAILING.STREfADDRESS �y ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY O Q T[ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY /J U ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE 11 k '� G� 3 Z6 Zv _2E41 IV. LEGAL NOTIFICATION AND BtLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. I APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY R FACILITY ID N 0 of TANKS N SITE 39 I dot 6 I I I 10101ol CURRENT LOCALVAT1KTYN�� APPROVED BYNAME PHONE WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO CODE CENSUS TRACT ee) SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO /�.� \ CHECK PERMIT AMOUNT SURCHARGE IMOUNT 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. +I FORM A(32-88) �^ DATA PROCESSING COPY w