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STATE OF CALIFORNIA WATER RESOURCES CONTR BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMS M" SITE I, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE `��I, a�� > ONE NMARKLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E 7 ENTLY CLOSED SITE El 2 INTERIM PERMIT q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I q91 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) to FACILITY/SITE NAME CAR O F ADDRESS INFORMATION ADDRE NE RES OR05SS FEET ✓80 to indicate PARTNERSHIP STATE AGENCY N � �� 1111�' ❑ CORPORATION ❑ LOCAt AGENCY DEAA-AGENCY 11wolvmuAL 11COUNTY-AGENCY (,V CITY NAME STATE ZIPCO ITE PHO p,WITH EA CODE Cn CA TYPE OF BUSINESS. 2 DISTRIBU Ofl 4 7flOCESSOfl ✓Box if INDIAN EPA ID a I GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ Aol TANK'a TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMER ENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PH NE ft WITH AREA CODE DAYS:JAM (LASTONE p WITH,FIRST( / AREA CODE 1 NIGHTS N ME(LAST,FIRST) SPH NE#WITH AREA CODE NIGHTS EE PLAIT FIRST) PHONEp WITH AREA CODE S S Ala 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAM CARE OF AD SS INFORMATION MAILI o15 'AET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ TATE-AGENCY J'i� ❑ CORPORATION ❑ LOCAL-AGENCY EDER A NCV ❑ INDIVIDUAL ❑ CONN TV-AGENCY CITU NAME SlIJE ZIP CODE PHO E 1,NITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE JCOMPLETED) A NA CARE OF ESS INFORMATION MAILor EET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP El AGENCY ❑ CORPORATION LOCAL-AGENCY ERA AGENCY ❑ OIVIDUAL COUNTY-AGENCY CITY NpM /a STT E /(,�• ZIF✓a HD PSN p ITH AREA CODE IV. LEGAL FJNV\OTIFICATION AND BILLING ADDRESS 1LV\ CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE [� EaE= p o e CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 3-s6- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA ION CODE CENSUS TRA l`j� SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DAT FIL ` ✓ CNECKM PERMIT AMOUNTI SURCHARGE A CUNT 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 OHL ' 1P.ORMA(3-2-88) ��.1 DATA PROCESSING COPY