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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD SExE. F 1M\ t FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° Zto rTCOMPLETE THIS FORM FOR EACH FACILITY/SITE "L'rOR MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ISL7 PERMANENTLY CLOSED SITE F"A' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE (01 0 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION F• ADDRESS NEAREST CROSS STREET ✓Bawexia@ 0 PARTNERSHIP 0 STATE-AGENCY SO � 4Ui� �`vn� [I OR .AGENC d ✓ �101ADUaO eaia CITY NAME STATE ZIP CODE SITE PH E k WITH AREA CODE I, 42C.ct- CA 533 20cf 823 -658y TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a RESERVATION or !i of TANK'e ❑ I GAS STATION ❑ 3 FARM 6?5 OTHER TRUST LANDS ❑ it AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE er Z_&?_s23_4• q OK/J NIGHTS: E(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS. NAME LAST.FIRST) PHONE 4 WITH AREA CODE a �6_ e Lo -?2-_?- S_ N 11. PROPERTY OWNER I FORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMFZ 'p CARE OF ADDRESS INFORMATION E�YIIIl. MAILING or STREET ADDRESS ✓Box to intlicale D PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. ' it. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION IT AGENCY K FACILITY ID R M of TANKS at SITE = = 6 X2- 3 y 101610131 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE P,&-I 1S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �N LOCATION CODE CENSUS TRACT F SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED YES ❑ NO ❑ s:�-- CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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 FORM A(3-2-88) *40I/ DATA PROCESSING COPY ``/