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STATE OF CALIFORN& WATER RESOURCES CONTAOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE `"�•�a"`" MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ LY CLOSED SITE I..► ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 4 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION PF"Y444*0 )ntG-5 AM ADDRESS /Xy may/ ^-/ NEAREST CROSS STREET ,/ ✓B0.Lo YdIkes 0 PAWNBISHIP 0STATE-AGENCY V + ctc WI C DI �/�/1P ❑ �PoMNGN ❑ LOGAWAGENY ❑ FEO RAL AGENN /1 ❑ INDNIDUAL 0 CWNNAGENCV CITY NAME STATE ZIP CODE SITE PHONE#,WITU AREA CODE N CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ESSOR '/Box if INDIAN EPA ID #RESER #of TANK'c TRUSTLANDS or ❑ ❑ 1 GASSTATION ❑ 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: yyy��^E(LA T,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE Kpini5 —c/, -(K0 NIGHTS: NAME(LAST,FI ) PHONE#WITH AREA CODE NIGHTS. NAME(LAS FIRST) HONE k WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION AIR S" MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME 4 m SAV/Ai v4ZMAI CARE OF ADDRESS INFORMATION MAILING or STREET ADOR SS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY , ' p ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY t • 1 YV�p, 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE �� ZIP CO�DE PHONE /#.WITH AREA/JCODE V!'"s IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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# FACILITY ID# #Of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY�ME PHONE#WITH AREA CODE PERMIT NUMBER "'1 Z PERMIT APPROVAL DATE (/v 2- 7,14 PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# G SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED O YES NO CHECK# PERM) 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 ONLY. FORM A(3-248) . DATA PROCESSING COPY Yb-7