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STATE OF CALIFORNIA WATER RESOURCES CONTROLBOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : a / COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED STE LO N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 19 J V I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) Cn FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 5# cv ADDRESS NEAREST CROSS STREET ✓So,to inmate ❑ PARTNERSHIP ❑ STATE AGENCY - ❑ CORPORATION Cl LOCALAGENCY ❑ FEDERALAGaa 47/4 Z41- Q!`1 1 ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE o CA 9 Zo�t1 e?cf3-6 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4,PROCESSOR ✓Box if INDIAN EPA ID # /'C #of TANK'SRESER �f E] 1 GASSTATION ❑ 3 FARM 5 OTHER TRUSTVATION LANDS D ElA/i AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST( PHONE#WITH AREA CODE 5-u,fl (&I 14,jifi2� 4N3- NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) SPAIilf NAME CARE OF ADDRESS INFORMATION �v/��I G MAILING or TWEET ADDRESS ✓Box to indicate ElPARTNERSHIP ❑ STATE-AGENCY MV�ii/�r' ❑ PERORATION ❑ LOCALAGENCY ❑ FEDERALAGENCYR /Y .4010r INDIVIDUAL Cl COUNTY-AGENCY CITY NAMEO0 STATE _ ZIP CODE PHONE z4q)�43 WITH EAC Dj� E III. TANK OWNER INFORMATION & ADDRESS — (MUST BEGCOMPLETED) 61 NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS Be.✓ t.'od'cate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ 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. II. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE U / I 5 2 CURRENT LOCAL AGENCY FACILITY ID# .x APPROVED BY NAME PHONE#WITH AREA CODE Yrtl PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE E DE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: n V\\ THIS FORM MUST BE ACCOMPANIED BY ATI`'ST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY./ FORM A(3-2-88) l a., - � I }'1'f ). DATA PROCESSING COPY ��