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STATE OF CALIFORNIA* WATER RESOURCES CONTROLBO-ARD � t � � W a FORM `A': UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) w CO FACILIT Y/SITE NAME CARE OF ADDRESS INFORMATION M� ADDRESS NEAR ST CROSS STREET ✓ Io irvicale 0 PARTNERSHIP 0 STATE AGENCY CORPoHFTION D LOCAL AGENCY 0 FEDERALAGENCY ,U z D INDMDUAL D COUNTY AGENCY CITY NAME ^ STAT^A ZIP CODE S TE PHON M,`A'ITH ARE OD/ TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F__] 4 PROCESSOR ✓Box if INDIAN EPA IID N X3oFl/TOAN'71K's C/O- ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION 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 X WITH AREA CODE C�a If - 43 a�9 5��7- 3 NIGHTS: NAME(LAST, IRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST, ST) PHONE X WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S fx'�w Faht4- cam;`o"--- MAILINor STREET ADDRESS %/Box to indicate 0 PARTNERSHIP D STATE-AGENCY O • a v3 D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY 0 INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE E P��'Wk AR DE dCP 14c/ HOINE# III. TANK OWNEA INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or ST EET AODRE -v/Be.lointlicate 0 PARTNERSHIP D STATEAGENCY ❑ CORPORATION D LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X.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. ❑ II. 111.❑ 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 N JURISDICTION N AGENCY X FACILITY-1 N of TANKS at SITE [�] © o ",-k 1 11 p06 CURRENT LO ENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE 5A I PERMIT NUMBER ERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECKI CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE4FEE BUSINESSPUN FILED NO ❑ DATE EFFILE �O ^0 PERMIT AMOUNT SURCHARGE AMOUNT ERECEIPT N BY: `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 ONLY FORMA(3-2-88) �I DATA PROCESSING COPY ` \'