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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 —� COMPLETE THIS FORM FOR EACH FACILITY/SITE F7 MARK ONLY LIQ NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 REBU&UqNTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE vl ,z 10 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FAV TY/SITE NAME CARE OF DDRESS INFORMATION aw ADDRESS NEARE CROSS STREET ✓&0x ,Micre ❑ PAAT MIR ❑ STATE-AGM �1 T ❑ CONPOMTION 13 LOCAL-AGENCY ❑ L ENCY Iw`NI[� $ $"6 N ❑ INDIVIDUAL ❑ (AUNTY AGENCY MME STATE ZIP CODESITE HONE#,WITH AREA CODE �, CA Z 7 27Lzr TYPE OF USINE ❑ 2 DI5IAIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN .EPA ID a 0 a TANKY 1 GAS STATION ❑3 FARM ❑ 5 OTHER RESEP TRUSTRESERYLANDS ATION of ❑ #/I/ AT THIS SITE Y� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) I' DAYS: NAM (LAST,FIRST) PHONE N WITH AREA CODE DAYS: NA E(LAST,FIRST) PHO xWITH AREA CODE 2a1) 1Z'1-fZS7 Q /� HTS: N (LAST,FIRST) PHONE p WITH AREA CODE NIGHTS:- AME(LAST,FIRST) P WITH AREA CODE 72"A 72'��Z� S T/Ay 11. PROP Y OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAM CARE OF f.DRESS INFORMATION MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ("�O I I+ /ATi/ ❑ CORPORATION LOCALAGENCYEDER l-AGENCY J N of Y ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZI�� PHONE ,WITH AREA CODE III. TANK O ER INFORMATION & ADDRESS - (MUST BE COMPLETED) 2 NAME D CARE OF RESS INFORMATION MAILINGor STREET AD EBS J ox to indicate El PARTNERSHIP ❑ STATE-AGENCY ElCORPORATION ElLOCAL-AGENCYFE Ep )CENCY •0+ ❑ INDIVIDUAL ❑ COUNTY-AGENCY (NAV CITY N 0 STATE -. ZIP CODE-,3 P�E p, ITjAREA GO�� _� IV. LEGAL( NO (CATION AND BILLING ADDRESS /�`/�C L(j)Ir Llll CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY IICOO�INTY�Y# I JURISDICTION# AGENCY# FACILITY ID# #o1 TANKS at SITE [H = 06 ► y 7 0d D CURRENT LOCAL AGENCY FACILITY ID# APPROVED B ME PHONE#WITH AREA CODE 11Z Ps I NK_ Lf/yj PERMIT NUMBER PERMITA gV/l#UA E PERMIT EXPIRATION DATE LOCATONCODE CENSUSTRACTA##� SUU'PE/RRVVIIISS(JR-DISTRICT CODE BUSINESS PLAN FILED DATE ILE +�C/ VM YES NO CHECK# PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPTM 43Y: 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 /�