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STATE OF CALIFORNIO WATER RESOURCES CONTROROARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 10', NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7TLY CLOSED SITE ONE ITEM E:] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE OI 2-0 go I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CILHY/SIT NAME / CAREOFAOpRF�SS INFORMATION ADDRE y • `WAYy/•�I/, NEARNST OR/O✓3SI STR T I/B.10 ldii ❑ PARTNERSHIP ❑ STATE AGENCY Dh� �/� ,� v{I 1 ❑ CORPORATION ❑ LOCAL ❑ EDEAAL GENCY v W o o a ` ❑ INDIVIDUAL ❑ COUNIV-AGENCY CITY NAM Al STATCA ZIPCODE SINEp WIT/AREAACODE �� TYPE OF BUSINESS: DOI_ST—RIBUTOfl ❑ 4 PROCESSOR ✓Bo%if INDIAN EPA ID # RESERVATION or //�� ,//)1 #ai 7ANK'a GASSTATION 1-13 FARM ❑ 5 OTHER TRUST LANDS ❑ ['�/ A AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAV NAME(LAST,FI T) PHONE#WITH AREA CODE DAYS: NAp E AST,FIRST) PHONE#WITH AREA CODE f 9 727 -shy S / ql b)(/-z3_19 NI TS. NAME( T FIRST gqPHgO E#WITH AREA CODE NIGHTS. N,[MjE(LAST,FIRST) PH/ONE#WITH AREA CO E ZV I377:7 ! � `771` II. PRO ERT OWN R INFORMATION & ADDRESS - (MUST BE COMPLETED) Ni - CARE OFA (&SS INFORMATION i A.,';l MAILING or STREET ,ESS (' -/B4 to Indicate El PARTNERSHIP FISTATE-AGENCY O / J( Ll CORPORATION ❑ LOCAL-AGENCY ❑ F DER -AGENCY v U ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY ME ST � ZIP CODE�� ONE ITH AREA CODE (J III. TANK OWN INFORMATION &ADDRESS - (MUST BE COMPLETED) 2 7-0- 2 (J� (�L NAM 041 �T • CARE OF ADDDEV INFORMATION 114 MAILI IREET ADDRESS /lam/-', ✓Nox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY W• r��,.y/1�1 // ❑ CORPORATION 11LOCAL-AGENCY DERAL GENCY �(� v% (/`�V W El INDIVIDUAL ClCOUNTY-AGENCY VI CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE 18 Iqj IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL Efr III. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE Oo 00 1 03 CURRENT LOCAL AGE1 CY FACILITY ID# APD VED Y NAME '1 ., , PERMIT NUMBER PHONE#WITH AREA CODE —t1 PE IT APP OVAL DATE P(EERMIT EXPIRRAATION DATE � LOCATION CODE CENSUS TRACT# SUPI-RVIS05-DISTRICT CODE BUSINES YES PLAN FILED NG ❑ DAT FIL D efq CHECK# PERMIT AMOUNT SURCHARGE AM/-000NT FEE CODE RECEIPT M 8 V: 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(3-2-88) . DATA PROCESSING COPY