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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5` FORMW:: UNDERGROUND STORAGE TANK PROGRAM m'" SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o ALJ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ITE I"N' ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) F SITE NAME / n e , / CARE O S INFORMATION ADD R LAC//ILLS/(l/_ /q/�t/J {/1�`J NEA ((CR��0f��S/-163 ✓AmWi ❑ PAFMEASHIP Cl STATE-AGENCY 6 `� FT�N'P- ❑ MVINDWMTION 0 LOOkAGENCY AGENLY ML AG CITY N STATE ZIP OdE SITE PHONE WITH AREA CODE o-/ CA d - z76 TYPE F BuSwEss. ❑ 2 DISTRIBUTOR F__] 4 PROCESSOR ✓Box if INDIAN EPA ID It E] I GAS STATION E] 3 FARM OTHER ESETRUSTVATION LANDSo ❑ 6D�rV/P ATTHIISSITE ®d EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) OA S: NA (LAST,FI PHONE-H WITH AREA CODE DAV ME(LAST FIRST) PHOIIN p TH AREA CODE NIGHTS: NAME ST,FIRST) PHONE JIWITH AHEA CODE NIGHT AM (LAST,FIRST) PHONE p ITH AREA CODE 7 , & A II. PROPE TY OWNER INFORMA 10 &ADDRESS - (MUST BE COMPLETED) NAMq n / CARE 05�ESS INFORMATION LA(JAL,J 0T /(�J MAILIN STRE� DRE$ A ✓ ox to RATIIO ❑ PARTNERSHIP ❑ STATE-AGENCY SSCl CORPORATION ❑ LOCAL-AGENCY ❑ F ERA G CV ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMESTATE - ZIP CODE PHONE#, I AREA CODE A7 d ,t,cKJ co./'0o 2, 3-ZLT III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME / - CARE OF ADDRESS INFORMATION MAILING or STREET ADD ESS µ•�D/ ✓Box la indicate ❑ PARTNERSHIP El STATE-AGENCY ❑ CORPORATION I] LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ If. 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 N JURISDICTION R AGENCY M FACILITY ID R M of TANKS BI SITE Ull = = 16 1 o 120 %( 10 1 1 Do 16 16 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY N E PHONE N WITH AREA CODE S o /'/6- $ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC TIO ODE CENSUS TRACT QN h SUPERVI7-j)ISTRtCT CODE BUSINESS PLAN FILED jVATE FILED O V YES NO CHECKW 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. \ 1 , FORM A(3-2-88) ,ULVI L/ DATA PROCESSING COPY •--f