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...� .�.. . ,. . __ .." --. �-_..,. . .P-_ STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD o. FORM 'A': UNDERGROUND STORAGE TANK PROGRAM t .. �' SITE J / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� 10 " � . z 10 COMPLETE THIS FORM FOR EACH CILITY/SITE `+<„QaH�a MARK ONLY ❑ T NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PUIMWNTLy I"A' ONE ITEM ❑p INTERIM PERMIT ❑0 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C. I. FACILITY/SITE INFORMATION III ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME T //'� CARE OF ADDRESS INFORMATION Oc V IA ADDRESS ((// ��/ NEAREST CROSS STREET ✓Bpr lovkink NERi11P ❑ STATE AGENCY oO 5 /`Q YN/L� 11 CORPORATION LOGLAGENLY ❑ FBM AGRM,Y ❑ INOYI L Cama AGENCY CITY NAME STATE ZIP CODE SITE PHONE N�yITH AREA CODE AA 641 CA C D s� TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR PROCESSOR ✓BOx if I IAN EPA ID p B of ❑ 1 GAS STATION 3 FARM 5 OTHER TRUSTYLANDS or ❑ AT THISHIS 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 tZy NIGHTS: NAM (LAST,FIRST) PONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME 5CARE OF ADDRESS INFORMATION r� a5 MAILING or STREET ADDRESS ✓Box to,ftcate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME sn^I- , p _v CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box Lo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ 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: LID' IL ❑ 111.❑ 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* JURISDICTION R AGENCY R FACILITY ID R k of TANKS at SITE © e I / I q7 0OO CURRENT LOCAL AGENCY FA LITY ID N Y APPROVED BY NAME PHONE N WITH AREA CODE "V V F 3 / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E"IRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR OISTFIN ODE BUSINESS PLAN FILED DATE FILED Z O 3 X YES ❑ NO ❑ —�— CHECK s PERMIT AMOUNT SURCHARGE AMOUN 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. .YFORM A(3-2-83) ,W\I � DATA PROCESSING COPY '�.