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.+,� ... yb.^,..:T.:Tg - ._ .....�TT ,., .; ,,. "'�' "�"_.---•.- p.;.—.—^--•�1'-•--�T•Y-''—..�..T, STATE OF CALIFORNIAr WATER RESOURCES CONTROYeOARD W. FORM 'A': UNDERGROUND STORAGE TANK PROGRAM = " " SI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; 1© �� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWALPERMIT f CHANGE OF INFORMATION ❑7 PERMANENTL LOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT - ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) F Y' FACILITY/SITE NAME CARE OF ADDRESS INFORMATION s e Go' ADDRESS Ile a NEAREST CROSS STREET ✓E10W.nN 11 PN1NASXP ❑ STAIEA690 ❑ ow ❑ uOcaLncExa ❑ FEnErul-ACEp w rrre � ❑ COUNWAGENOf CITY NAME SfATE ZIP CODE SITE PFIGNE 4,WITH AREA CODE CA 303 406 -517/ TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑4 ROCESSOR ✓BOK if INDIAN EPA ID p RESERVATIONOr /�A F/I�� X of TANK's ❑ IGASSTATION 03FARM OTHER TRUST LANDS .❑ `-s AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,fIRIfT)_�4i�t, �` _// PHONEp WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONEp WITH AREA CODE NIGHTS: NAME( ,FIRST) l.•//I1 J/r /�/++JPHONE p[WIITHH AREA CODE 1NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION G,p,or e Lec h i cl_ MAILING or STREET AQJRESS ✓Box to i,ftate ❑ PARTNERSHIP ❑ STATE-AGENCY C �V '�^ ❑ C PORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY J L IVIDUAL ❑ COUNTY-AGENCY _ CITU NAME STATE 21P CODE PHONE,WITH AREA CODE Sfo G!3 1 f6ao� w Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME 9// p CARE OF ADDRESS INFORMATION Y G li/��1 MAILING o,STREET SS ✓Box toindicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ PORATION ElLOCAL-AGENCY 13FEDERAL-AGENCY DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE 21P CODE PHONE p,WITH AREA CODE C IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK 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 Y JURISDICTION B AGENCY N FACILITY ID M a of TANKS at SITE CURRENT LOCAL AGENCY FACILITY D Y APPROVED BY NAME PHONE p WITH AREA CODE Ie PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (� YES El NO 6 CHECKX PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTY 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 ONLY. FORM A(32-BB) �� DATA PROCESSING COPY _