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a STATE OF CALIFORNIM' WATER RESOURCES CONTRO�OARDFORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION PERMANENTLY CLOSED SITE F"a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NA b CARE OF ADDRESS INFORMATION ADDRESS /� NEAREST CROSS STREET ✓ iGinle 0 PAAIMIBHIP 0 STATE AGENCY O( L 0 (I J-e. SyLR 0 INOMMT o `ca GEN ❑ RmuL.AGEraLv CITY NAMESTATE ZIP CIE SITE PHONE N,WITH AREA CODE 5+kr CA �ZOC� TYPE OF BUSINESS'. 2DISTRIBUTOR ❑ 4PROCESSOR ✓BDxd INDIAN EPA ID N SpI TANMt ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSTVLANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE If WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ]q /J CARE OF ADDRESS INFORMATION U 1�(` Y � MAILING or STREET D RESS _✓_ Bpx�W��r�dcate 0 PARTNERSHIP 0 STATE-AGENCY Ay6��1 L�lCO{iPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Qco Vr) 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE C WITH AREA CODE L(lm! ocL KP L 3.3514 % 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 5a rxi ab 1 MAILING or STREET ADDRESS ✓Box to intlicale 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE IN,WITH AREA CODE IV. LEGAL NOTIFICATION 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY M FACILITY ID S S of TANKS a1 SITE [H51 0 10 1 al 0 I a I3 0 0 U CURRENT LOCAL AGENCY FACILI VL4D k APPROVED BY NAME PHONE 0 WITH AREA CODE ETA PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION ODE CENSUS TRACT R SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED OL4y-0 YES NO l a CHECK PERMIT 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(3-2-88) ",41 DATA PROCESSING COPY 7E xt