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iV- P STATE OF �PALIFORNJO WATER RESOURCES CONTR OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7PEEN TLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE D O I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME / CARE OF DOPERS INFORMATION AI 41 r\3 NEARS ROSS STREET ✓ mlo ln4male El PARTNERSHIP [I STATE AGENCY ADDR CORPORATION ❑ LOCAL FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NA E r STATE ZIPSITE Q6-� 20H N-36rAREA CODE I CA S TYPE OF BUST 2 DISTRIBUTOR 4 PROCESSOR ✓Bax if INDIAN EPA ID If #of TANK's RESERVATION or 1 GASSTATION E 3 FARM 5 OTHER TRUST LANDSEl AT THIS SITE L,/ EMERGENCY CONTACT PERSON(PRIMARY) EMERG NCY CONTACT PERSON(SECONDARY) A NAME(LAST,FIRST) PH NEN WITH AREA CODE DAYS 1JA (jAST,FIRST) PHONE WITH AREA CODE 26 333-6.66 Jc /IT S 4 NIGHTS'. AME(LAST,FIRS P ONE N WITH AREA CODE NIGHTS' IJE(LAST,FIRST) PHONE WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE F D RESS INFORMATION MAI Gor STREET RE58 S ✓B�To indicaTe ❑ PARTNERSHIP ❑ STATE-AGENCY ACJ? E3 INDIVIDUAL 11 LOCAL AGENCY ❑ COUNTY AGENCY ❑ FEDERAL-AGENCY CITY NA STfjTE ZIP ODE PHONE WH.Ai ODE CITY / C f/-1� 3 6 III. TANK OWNEFUNFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF jDqESS INFORMATION MAILIN or STREE A ORES ✓ xTO lndlcaT¢ ❑ PARTNERSHIP ❑ STATE AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITU NAME ST E ZIPCO0 PHONE WI AREA CODE IV. LEGAL N TIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. 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 P JURISDICTION R AGENCY IN FACILITY ID N N of TANKS at SITE CURRENT LOCAL AGENCY yFACIL�ITY ID Jr APPROVED SY NAME PHONE M WITH AREA CODE PERMIT NUMBER 6/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC ION CODE CENSUS TRi SUPERVIS R-DISTRICT CODE BUSINESS ,.P SN FILED NO ❑ D L �{x�J� 3 (JO'O RECEIPTM VVVAY OAt( CH K PEPMIT AMOUNT SURCHARGE OUNT FEE CODE 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 s FORM A(3-2-88) a DATA PROCESSING COPY & '