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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD Stt• l4f FORM 'A': UNDERGROUND STORAGE TANK PROGRAM = " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO Z �- 30 C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT j j 5 CHANGE OF INFORMATION 7 RMANENTLY CLOSED SITE I" ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G97 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 1 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION SBMar ADDRESS NEARESTCRO SSTFEET ✓am a YAkaa El PARTNERSHIP ❑ STATE AGENCY /303 y' S� ❑ OAPORAT10N ❑ LGGI�AGENCY ❑ FEDERAL-AGENCY 111 , YYV Nj` INGmGUAL ❑ (AUNTY-A6ENCY CITY NAM STATE ZIP CODE SITE PHONE N.WITH AREA CODE NAA CA TYPE OF BUSINESS-. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N ❑ ❑ TRUSTYLANDS or ❑ M of TAN 'a 1 GAS STATION 3 FARM 5 OTHER pT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE Case -&38'-2926 USN NIGHTS: NAME(LASE FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 2O 83g-:2L2h U�CN II. PROPERTY OWN6 INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME LL CARE OF ADDRESS INFO ATI MAILINGor T EETADDR SS ✓Boxm ntlicaie 13 PARTNERSHIP ❑ STATE-AGENCY /\��,,/�. ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY Y ❑ INDIVIDUAL 11 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 6sc&1oN e 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAM ^ o'g CARE OF ADDRESS INFORMATION W � `v MAILING or STREET ADDRESS ✓Box la ir,aicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. 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 N JURISDICTION It AGENCY W FACILITY ID TO a of TANKS at SITE Dao oaoo CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPE STRICT CODE BUSINESS PLAN FILED DATE FILED 231 80 YES NO � G ALL CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) ''►�Y DATA PROCESSING COPY ..�