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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD { ) FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE ' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE F G0o3 7&a MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 R9M9ENT`tV.CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACT /SITE N CARE OF ADDER S INFORMATION D/ Z ADDRESS (�(. N EST GRO S E ✓Box lo,m.le ❑ PARTNERSHIP [I STATE AGENCY co �, C3CORPORATION OlOCALAGENCY El FEDERAL AGENCY[3co'^ INONIDUAL CY COUNTY CITY NAME STATE ZIP CODESITE PHO E p, Lod-t CAITH AREA CODE Sz l7 Oct0 /i TYPE OF BUSINESS: ❑2 DISTRIBUTOR PROCESSOR ✓Box it INDIAN EPA ID w #of TANK'S ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUSTVLANDS or ❑ AT THIS SITE D 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) OAVS NAME(LAST FIRST) PHONE p WITH AREA CODE DAYS. NA E(LAST.FIRST) PHONE N WITH AREA CODE � o Z�r9 z- 671 S A NIGHTS'. NAME( .FIRST) PHONE WITH AR ACODE NIGHTS VAME(LAST.FIRST) PH EN WITH AREA CODE SM 4 GS- S II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE 0,F)ADDRESS INFORMATION AAA MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY /� / J ❑ CORPORATION ❑yOCAL-AGENCY ❑ FEDERAL-AGENCY (/� Ill/ ❑ INDIVIDUAL I�COD TY AGENCY CITY NFMEO5STATE ZIP CODE HONE ,WITH AREA CODE Ddb s'zb z 5��-Y �r III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME IN CARE OF ADDRESS INFORMATION 5 AILING or STREET ADOPT ✓Box to,nd,cate ❑ PARTNERSHIP [ISTATE-AGENCY 1+ ❑ CORPORATION El LOCAL-AGENCY ❑ FEDERAL-AGENCY [I INDIVIDUAL [ICOUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE j ) IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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 a AGENCY# FACILITY ID# If of TANKS at SITE [il�lob 0 1 lo I 3 ENCY FACILITY ID# APP OVE BY NAME PHONE#WITH AREA CODE CU ENToC ; PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPI ATION DATE LOCATION CODE CENSUS TR T# SUPERVI OR-DISTRICT CODE BUSINESS PIAN FILED DAT F,I YES ❑ NO CHECK M PERMIT AMOUNT SUR HAP E AMOUNT FEE CODE RECEIPT# BY: ass \ 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) BEF4 DATA PROCESSING COPY �= J