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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD Q .t saA FORM `A': UNDERGROUND STORAGE TANK PROGRAM z SITE FACILITY/SITE, INFORMATION and/or PER APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE � ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE 1 NEW PERMIT ❑3 RENEWAL PERMIT O W MARK ONLY ❑ ❑4 AMENDED PERMIT ❑ 6 TEMPORA SITE CLOSURE � ONE ITEM ❑2 INTERIM PERMIT ST BE COMPLETED) cn I. FACILITY/SITE INFORMATION & ADDRESS —(MU --.A1 T�llu CARE OF>^"-- FACILITY/SITE NAME LctrT� S L n _ U.1 ly L r c, O 1� NEAREST CROSS STR ET ✓Bwbrdeale 0 PwiNE 0 STATE AGENCY p � ❑ CDPPOAAiION ❑ LOCAL-AGBKY ❑ FE EPALAG C ADDRESS A.r( A� R Lt rl n ❑ INDMOUAL 0 COUNTY AGENCY 3 '�j - J ZIP CODE SITE PHONE N,WITH AREA CODE _ STATE p y CITY NAME 1 CA EPA M N N of TANK'S TYPE OF BUSINESS'. ❑2 DISTRIBUTOR ❑ 4 PROCESSOR -/BoxitRESERVATITONN or or �� AT THIS SITE �lYO F-1I GAS STATION ❑ 3 FARM fHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(SECONDARY) EMERGENCY CONTACT PERSON(PRIMARY) PHONE N WITH AREA CODE PHONE M WITH AREA CODE DAYS'. NAME(LAST,FIRST) DAYS'. NAME(LAST,FIRST�- PHONE M WITH AREA CODE NIGHTSNAME(LASTFIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) '. , L( h dl -xZo g ^ 3m RESS — (MUST BE COMPLETED) 11. PROPERTY OWNER INFORMATION & ADD CARE OF ADDRES IN!, IM( Q \TION NAME ' O 1�+`i- IIJIN"/IL ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY MAILING or ST{LEETOADDR S I 0 C pIVIDUALON 0 COUNTY-AGENCY LOCAL AGENCY 0 FEDERAL-AGENCY IfiIJJ STAT ZIP CODE PHONE a,WITH AREA CODE S Z v l CITY NAME III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME ^' /Y /�A l.j'ri 0 STATE-AGENCY ✓Box to indicate 0 PARTNERSHIP MAILING Or STREET ADDRESS 0 CORPORATION � COUNTY-AGENCY OFEDERAL-AGENCY ❑ INDIVIDUAL PHONE Jr.WITH AREA CODE STATE ZIP CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. If.El if. 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) LOCAL AGENCY USE ONLY FACILITY ID R R of TANKS9COGE JURISDICTION B AGENCY k 9/� COUNTY If � � ^I 0 O ® 0 l PHONE M WITH A APPROVED BY NAME CURRENT LOCAL AGENCY FACILITY IDN A^ I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE GATE 1—ca BUSINESS PLAN FILED NO ❑ 1-`+' �j9 SUPERVI80R-DI TRICT CODE YES � `��' LOCATION CODE CENSUS TRACTM `/D RECEIPT BY: CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE K PERMIT FORM `B'APPLICATION(S),UNLESSTHIS ISACHANGE OF SITE INFORMATION ONLY. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1) MORE TAN FORM A(3-2-83) DATA PROCESSING COPY