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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "`'l'` FORM 'A': 1, �" UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z C/ COMPLETE THIS FORM FOR EACH FACILITY/SITE "�� B� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT DrtNGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �3 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) v FACILITY/SITE NAME CARE OF ADDRESS INFORMATION -J-C5e e/C ADDRESS NEAREST CROSS STREET ✓60 to irNA0 0 PWMRSHW 0 STATE AGENLY 0 CORPORATION 13 LOCAL-AGENCY 0 FEDERAL AGENCY fo C,C cR/p BelOTC! IeW, Zc2l?e ❑ INDIVIDUAL ❑ WUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE £s cu/oar CA /-X-'/-2- PZP7i TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box N INDIAN EPA ID N Oat TANK# L-!4 "'GAS STATION ❑ 3FARM ❑ SOTHEfl 7RUBTUNDS or ❑ AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE J S Se trJe /c_ A /-eV - ;2?' 75- / - ac38 'a/d.t NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Se55e WG/C l-1 - �3F1-aloes MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY pp D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY i 6) 1S 7 C S CLCD n 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE G'ScaG e'er $�� III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sq/7w LZ S :22-- MAILING LMAILING or STREET ADDRESS ✓Boz to indroate 0 PARTNERSHIP D STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY D 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. ❑ II. 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 N JURISDICTION M AGENCY N FACILITY ID N N of TANKS at SITE 3 I I I I a y 0 1 0 I 0 I 3 URRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE N WITH AREA CODE I PERMIT N IT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED/,? a 3 E-0 3,P-{, YES NO C-] �( qU CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST RI OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNEESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) vq Ci 0 DATA PROCESSING COPY