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I STATEALIFORNIA� WATER RESOURCES CONTROL BOARD ` FORM `A': I UNDERGROUND STORAGE TANK PROGRAM �°" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONjw m �� o III COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERM LOSED SITE F'a ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 00 1.FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) r O FACILITY/SITE NAMECARE OF ADDRESS INFORMATION Y ADDRESS NEAREST CROSS STREET ✓80l0Mc0e ❑ PARMETISHIP ❑ STATEAGENCY /1 p El CORPORATION ❑ LOGL-AGENCY ❑ FEDENAL AGENCY `O ry oC J O � N/ SSO/�1 /\ ❑ INUMAL ❑ CWNrY AGENCY CITY NAME STATE ZIP CODE SITE PHONE It.WITH AREA CAGE &)-.-7{D/? CA 95.103 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID# ❑ 1 GAS STATION FARM ❑ S OTHER TRESTTVLA6 ATION Gr ❑ AT THIS SITE ®/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE f WITH AREA CODE j u /C- NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 61/C a!Nr IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION .j Ct Wre// / " MAILING or STREET ADDRESS ✓Bointlicale 13 PARTNERSHIP 11STATE-AGENCY ^lO 11RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY j J cL)- /-P e" cin f INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE C4 gsao3 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S� I MAILING or STREET ADDRESS j� ✓Rox to care ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODEPHONE f.WITH AREA CODE 4_ 1 IV. LEGAL NOTIFICATION AND BILLING ADDRESS I CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. lid 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 R JURISDICTION* AGENCY a FACILITY ID N *of TANKS at SITE U7Ual = = I I l I A /v 100C) / CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER TY/IL //�J JJV/PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT/FILED �c� 3, L 3� YES NO 2r V —13—d / CHECK* PERMIT ANNI SURCHARGE AMOUNT FEE CODE RECEIPT# BY: C 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(3-2-68) - DATA PROCESSING COPY .�..