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STATE OF CALIFORNIA WATER RESOURCES CONTROL40ARD FORM A: UNDERGROUND STORAGE TANK PROGRAM Na SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION t� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUREllffl 10 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF AD HESS INFORMATION , rr N ADDRESS NEAREST CROSS STREET ✓Bm to inEvale D PAWNERSHIP Cl STATE AGENCY cjj O .� //� ❑ CORPORATION Cl LOCAL AGENCY D FEDEML AGENCY 0 mouAL D GDUNTY-AGENCY v CITY NAMESTATE ZIP CODE SITE PHONE N.WITH AREA CODE CA 9 -e TYPE OF BU NESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ROx ii INDIAN EPA ID a p Of TANK'e AS STATION ❑ 3FARM ❑ SOTHEfl TRUSTYLANDSION O ❑ /vorw& AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) �9T,(_ Rfr' P A�,IjdAREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE HTS: O2 - (o NIGNAME(LAST.F STI PHONE p WITH AREA CODE NI HTS'. NAME(LAST,F ST) ONE p WITH AREA CODE 0 II. PROPERTY O NER INF RMAT10 & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION P/7,1I/ ' hr� a MAILING or STREET ADDR SS ✓Box to ind'I Cl PARTNERSHIP 0 STATEAGENCY �'). Q D C RPORATION C LOCAL-AGENCY 0 FEDERALAGENCY (/ DIVIGLATT D COUNTY-AGENCY CITY NAME STATE I ZIP CODE I PHONE H,WITH AREA CODE a W7- -16 t10 Ill. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME �y�,- CARE OF ADDRESS INFORMATION .3rmixS MAILING or STREET ADDRESS ✓Bax to io0icete D PARTNERSHIP D STATE-AGENCY D CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE 0.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- 9111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANO CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTIONIN AGENCY# FACILITY ID If #of TANKS at SITE 3H 010 118 43 0 10d CURRENT LOCAL //AGGENCY FACILITY ID# APPROVED BY NAME PHONE 0 WITH AREA CODE 1-1 4O(J PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE N LOCATION CODE LMRUITAMLOUNT SUPERVISO -DISTRICT CO E BUSINESS PUN FILED DATE FILED �� a. YES NO ❑ '� lCHECK M SURCHARGE AMOUNT FEE CODE RECEIPT N BY: XFORMTHIS 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. A(3-2-88) `./ DATA PROCESSING COPY „�.