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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD j 5r�� 4F FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION i COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 570 I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION f_rel,c Cam gree-1 cuf4Lxt—J Se_rvtc.e e,e5c, ci ckt ADDRESS NEAREST CROSS STREET ✓BmbiiSrYe ❑ PARTN9WP ❑ STAIEAGENLY In l D ❑ CDPPMn0N ❑ LDDALAGENCY ❑ FEDEML-AGENCY 666 S �r�c N OS GI R ❑ N[YYQJ& ❑ CGMAGRICY CITY NAME STATO ZIP CODE SITE PHONE p.WITH AREA CODE F-rerad. wn CA 95 31 6 -sw( TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 'PROCESSOR ✓Box it INDIAN EPA ID p S of TANK's ESE ❑ I GAS STATION ❑ 3 FARM RR 5 OTHER TRUSTYATION LANDS or ❑ �,�, N AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE Or WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE LLTAt 09 x/66- NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE Biba -—, (Ir 9 - 0556 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ere 1 Rn qr e MAILING or STREET ADDRESSf ✓Box to inoicele ❑ PARTNERSHIP ❑ STATEAGENCY II� ) / ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Q -P1GhWLa N� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE k i,z CA �Sa U 7 u4�N III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION C1 e QS MAILING a STREET ADDRESS ✓Box to ineicpte ❑ PARTNERSHIP O STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL O COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVB ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11.0111. ❑ 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 S JURISDICTION R AGENCY N FACILITY ID N M of TANKS SI SITE c) 1c) 1--27F= 10 100E CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE If VIITH AREA CODE Q PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N BUPERVISOR•DIST111CT CODE BUSINESS P SN❑FILED NO ❑ DATE FIl/OC 99 23 . oz 1 O CHECK 0 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p ILL THIS FORM MUST BE ACCOMPANIED BY AT LEAST III OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORM ON ONLY. FORM A(3-2-BB)