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STATE OF CALIFORNIvs WATER RESOURCES CONTRtXC BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM . SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH F CILITY/SITE `'<rraaa`r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9 4 N I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE JAME 00 CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ to micam Cl PARTNERSHIP 0 STATE-AGENCY YL A j2 1-luiati M^ CORPOM70N 0 LOCAL 0 FEDERAL AGENCY �//` ❑ INDIVIDUAL 0 COUNTYAGENCY CITY NAME ^�� STATE ZIP CODE SITE PHONE A,WITH AREA CODE SI CA Q Y61-5475 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 P CESSOR ✓Box i11NDIAN EPA ID a ❑ 1 GASSTATION ❑ 3 FARM OTHER TRUSTYLANDS ATION or ❑ AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHO E p WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE o N aQ 105-567 NIGH : NAM(LLJNST,HRI PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Q/►iu CL S i` L MAILING or STREET ADDRESS ✓Box to intlicale 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Sox loictlicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.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. if. ❑ 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION R AGENCY B FACILITY ID B R o1 TANKS at SITE 1010 1010 10 13 CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME - PHONE N WITH AREA CODE , kL q 10 PERMIT NUMBIP Q PERMIT APPROVAL DATE ERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 YES ❑ No ❑ `� 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 IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-81) �� DATA PROCESSING COPY ^-'�