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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �! { ! FORM A: UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° : o E COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE I"� ONE ITEM ❑ 2 INTERIM PERMIT ❑/AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S CoCo 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) OD 4 FACILITY/SITE N'Ap E CARE F ADDRESS INFORMA ION V el I le c ,'c t_e 2 e n T 5� ADDRESS /� J �� NEA ST CROSS STREET B ❑ LOCALPARTNERSHIPADEN ❑ FEDERAAG ("111 LJl roreA� INDWARnna+ ❑ COUNTYAGEN ❑ FEOBu1ACBrcr ❑ Inomlxuu ❑ caulmACPxcY CITY NAME STATE CZIP�ODE�( SITE q,WITH AREA CODE A TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓BOX it INDIAN EPA ID # lJ x[—o]f1,TANCMojs J\� ElI GAS STATION ❑ 3 FRAM �S6THEfl TRUSESETLANDS or ❑ ATTHISSITE Uf�.11 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: AME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE S l:ee- NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE fZ_m se- ll. PLP e O II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION kvic (12) ( e . Ocr-v U-4- MAILING or :ET ADORE ✓ -to indicate 13 PA RTNERSHIP ❑ STATE-AGENCY _Q CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ CC UNTY-AGENCY CITY NAME5+ 1 r-) STAT 21P DE PHONE N,WITH AREA CODE q I 11—• G L, III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME � ^ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Q STATE-AGENCY ❑ CORPORATION ❑ LGCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE HONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. Er 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY N FACILITY ID x If of TANKS at SITE -Dl I 3 lP I I (DI O I O Fol CURRENTLOCAL CY FACILITY ID APPROVED BY NAME PHONE x WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK DE CENSUH�RACTN SUPERVISOR-D�ICT CODE BUSINESS PSN FILED NO ❑ DATE FILLD r PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE REGEIPTa (wr 1'B�Y::: 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 ON FORM A(3-2-131 • DATA PROCESSING COPY