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�1 S�\uir 4F STATE OF CALIFORNwA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM o Z �<: SITE T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Io D�\ 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION /x�/Y7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE w CD 1. FACILITY/SITE INFORMATION & ADDRESS —(MUST BE COMPLETED) R 0FADDRESS INF MAT FACILITY/SITE NAME � L � .� CAJ IQl/ Seri I so I NEAREST CROSS STREET ✓��P.p dP PA9INMIF El STATE AGEN N ADDRESS (d�C01PORAiNIN D LOCALAGENCY Cl FEOER1l-AGDO 'l N SpA 1^ S� � _ D.H� 94 0 INpNIDIIAL [I COU11TY.AGENCY CITY NAME O•La i0� ,'�L� STATE Z �T� $IT� NHAREA CODE TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA IDN V 1(�7 N of TANKl/s/�(D`' ❑ 1 GAS STATION ❑ 3 FARM ® 5 OTHEfl TRUSTVLANDS ATION or ❑ ��N AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE PHONE Al WITH AREA CODE NIGHT iI(It (LAST.FSR ) 2�_ PHONE N WITH AREA CODE NIGHT NA E(LAST,FIRST) w' l 11. PROPERTY OWNER INFORMATION &ACARESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION u +e bdl� MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRE S — (MUST BE COMPLETED) NAME _ CARE OF ADDRESS INFORMATION x�n11 !�Sd U� III MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D STATE AGENCY ❑ CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS R-J� CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Eit. ❑ Ill.❑ 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 N JURISDICTION N AGENCY N FACILITY IDN N of TANKS at SITE m10 1to 2 2 3 S 1 101010111 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE /�Ar LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 0 �3 ^/'1 YES � NO CHECXN PERMIT AMOUNT SURCHARG AMOUNT FEE CODE RECEIPTN 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 ONL . \ORM A(3-2-9e) '� DATA PROCESSING COPY *Iiol