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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE [wl 00 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Ps►Z ESS Cl F[ S [I STATE AGENCY ADDRY NEAREST CRDSS STREET Cl CO�0 TION ❑ Lau AGENCY ❑ FEDEFAL AGENCY S _r' ❑ INDMWAL ❑ COUNTY AGENCY CIN NAMESTATE ZIP CODE SITE PHONE N.WITH AREA CODE CA 9S-374 d — a Cl TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # M of TANK'1 E] 1 GAS STATION E]3 FARM El OTHER TgUSTYANDS ATION or ❑ AT THIS SITE / I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If Fj 5,v"0-,xaAf—y NIGHTS: NAME(LAST.FIRST) PH NE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME _ CARE OF ADDRESS INFORMATION MAILING or ST ADDRESS ✓Box to indicate ❑ PARTNERSHIP [ISTATE-AGENCY ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY 4 Q C INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP4DE PHONE k,WITH AREA CODE (S_3 3S Ill. TANK OWNER INFORMAliON &ADDRESS — (MUST BE COMPLETED) NAME �I_--A ^' l CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS`C (R 3 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY C CORPORATION C LOCAL-AGENCY C FEDERALAGENCY C INDIVIDUAL C COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,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: 1. ❑ If. ❑ 111.❑ 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 R JURISDICTION R AGENCYIN FACILITY ID R X of TANKS at SITE InlolaT:5= 4' 1 ol 0 CURRENT LOCAL AGENCY FACILITY 10 k APPROVED BY NAME PHONE k WITH AREA CODE �V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRIC CODE BUSINESS PLAN FILED DATE FI y38d YES NO CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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(3-2-88I DATA PROCESSING COPY L�