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SATE OF CALIFORNIA— WATER RESOURCES CONTROL-.HARD sa ORM `A': UNDERGROUND STORAGE TANK PROGRAM �m 0 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE / ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 10 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF.ADDDRESS INFORMATION ADDRESS L NEAREST ROSS STREET ✓�inbreb 0 PARTNERSHIP 0 STATE AGENCY e TION 0 LOCA4AGENIX 0 FWK-AGENCY INomouu 0 WUNTY-AGENCY CITY NAME STATE ZIP CODE S TE PHONE#,WITH AREA CODE �4 CA q5-2o � TYPE OF BUSINESS: ❑2 OtSTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a #of TANK's RESE ❑ 1 GAS STATION ❑ 3FARMER TRUSTVLANDS or ❑ AT THIS SITE O� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE RL T2OG 4I—L NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE (200 33 3 -$ZS( 5ilm E II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION N Nfyr{ MAILING or STREET ADDRESS ✓gK10 indicate 0 PARTNERSHIP 0 STATE-AGENCY O CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIPCCOODE PHONE WITHAREACODE v15 /tel III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADD ESS INFORMATION K MAILING or STREET ADDRESS ✓l�B�Ws.frc indicate 0 PARTNERSHIP 0 STATE-AGENCY CVCORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITY NgrKlkj STATE ZIP CODE NE N,WITH AREA CODE Co q5 ao 20 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. CVII. ❑ 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 M JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE UH O 5161 al c� - CURRENT LOCAL AGENCY FACILITY ID# APP VED BY NAM PHONE Y WITH AREA CODE PERMIT NUMBER PE APPROVAL DA PERMI EXPIRATION DATE 2 LOCATION CODE. CENSUUSS TRACT If SUPERV R--DIST CT CODE BUSINESS PLAN FILED DATE FILED qC CHECK# PIT AMO SURCHARGE AMOUNT FEECODE YES D ❑RECEIPT II ❑ BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESSTHIS IS A CHANGE OF SITE INFORMATIO FORM A(3-2-88) y '. DATA PROCESSING COPY �4