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SE^�vov rhe I� STATE OF CALIFORMA WATER RESOURCES CONTRbCBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSED$ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE 5 CA) I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) m FACILITY/SITE NAME C I�nS eG'h'�" CARE OF ADDRESS INFORMATION� I ADDRESS NLAREST CROSS STREET ✓Bm IO iM.11 ❑ PARMEBBHIP ❑ STATEAGBILY �� led ❑ CORPORATION El LOCAL-AGED El R➢EAALAMCP 1 O n 11INDNIDUu ❑ WUNnnGBICT CITY NAME1 �� STATCA Z, c! ;Lo 3 SITEPHOO 9 W"4451( CODE s / TYPE OF BUSINESS: 11 L2)DISTRIBBUTOR F-14 PROCESSOR ✓Box it INDIAN EPA ID a (—Jl J f7` P of TANK'a /� 1 GAS STATION ❑3 FARM ❑5 01HEfl TRUST LANDS ESERVATION or ❑ ATTHIS SITE w EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(UST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE m R o c e. aoq q(0(0 -.3691 NIGHTS: NAME(LA R ) 0q HONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST( PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMECCARE OF ADDRESS INFORMATION�leC�i"C� MAILING or STREET DDRESS ✓Box to intlicele ❑ PARTNERSHIP ❑ STATE-AGENCY /l ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY LJ 1(Jv ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME � I V ' V ST ZIP ZIPCOPE��O / �„FPHONE It,WIq(o (o ,3&, / IV. LEGAL NOTIFICATION AND BILLING ADDRESS /lL (73 9 � CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ Il. ❑ III.❑ 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 COUNTY• JURISDICTION# AGENCY# FACILITY IDN 2 R of TANKS at SITE ® = VTT ' I t 101010RE CURRENT LOCAL AGENCY FACILITY 10 r O L IPR ) /DI APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER /IPERMIT APPROVAL/ DATE PERMIT EXPIRATION DATE LDE CENGUSTRACTN BUPERV180R-DISTRICT CODE BUSINE88 PIAN FN.ED DA D4 ` YES NO ❑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 IS A CHANGE OF SITE INFORMATION 0 Y. V 0 RM A(3-2-88) -� DATA PRCCESSING COPY