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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD , FORM 'A': 7 UNDERGROUND STORAGE TANK PROGRAM e" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONZ _ o IO COMPLETE THIS FORM FOR EACH FACILITY/SITE `"'�•�^"" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT RIS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE � ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) co FACILITY/SITE NAME CARE OF ADDR S INFORMATION ADORE SS NEAREST CROSS STREET ✓SAWi 0 PARNSIISO Cl STATEAG90 3 I ❑ CDWMTIOa 0 IGGI.AGRILY Cl FEIM AGRILI INNYIGIPL ❑ WUIIY-AGBILY CITY IN STATE 7JQ CgpE� / SITE PHONE N.WITH AREA CODE 7L CA TYPE OF BUSINESS: ❑ 2 DISTRIBUT ❑ 4 PROCESSOR ✓Boz if INDIAN EPA 10 # ❑ I G4$STATION ❑ 3 FARM ❑ 5 OTHER TRUBTYLANDS ION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: AME(IAST,FIRST) PHONE M WITH AREA CODE DAY ME(LAST,FIRST) PHONE p WITH AREA CODE e o - /-�7 uxN NIGHTS' NAME(LAST,FIRST) PHONE a WITH EA CODE NIGHTS' NAME(LAST,FIRST) PHONE N WITH AREA CODE a u ?1 c191"1 II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME Op CARE OF ADDRESS INF MAT ON MAILING or STREET ADDRESS ✓ oz to loo"'als 0 PARTNERSHIP 0 STATE-AGENCY �^ Lp ORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 14<3 `1 IV l� INDIVIDUAL Cl COUNTY-AGENCY CITY NAME 5 ATE ZIP CODE PHONE p,WITH AREA CODE Ill. TANK TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME �/Q CARE OF ADDRESS INFORMATION rw MAILING or STREET ADDRESS ✓Box lo. Edlcm 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 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. ❑ ILAZ Ill. ❑ 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 N JURISDICTION M AGENCY M FACILITY ID B S o/TANKS EI SITE 3 ] = = 10a 111 s o 100 CURRENT LOCAL AGENCY FACILITY 10• APPROVED BY NAME PHONE X WITH AREA CODE � 3 -1 MAN&NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACT I SUPERVISOR-0IIITRICT CODE BUSINESS PLAN FILED OA FILED 2 O YES ❑ NO S CHECK E PERMIT AMOUNT SURCHARGE AMOUNT 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. / FORM A(3-2-83), (\/> DATA PROCESSING COPY �.,