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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Vm �o SITE , FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION T_ I COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7N-13 ERM TLY CLOSED SITE ONE ITEM ❑p RNTERIMPERMIT ❑ d AMENDEOPERMIT E]6 TEMPORARY SITE CLOSURE — Z 10 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACIL /SIT NAME CARE OF ADDRESS INFORMATION S P/ enc ry ADDRESS NEAREST CROSS STREET ✓ Aoxate 0 PARTNE�iIP ❑ ggiEAGENO' C.O f0llle0 LION ❑ LOCAL AGENCY D FEDEI L-AGENLV 0 INDIVIDUAL Cl COUNINAGENLY CITU NAME ^ STATE ZI ODE SITE PHONE p,WI H AREA CODE N \J CA Jo�D C.20cl Y66 -15763 TYPE OF BUSINESS: [D 2 DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA IO a E] I GAS STATION ❑3 FARM El OTHER TRUSTYATIO LANDS of ❑ A DI TANK' AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERG CY CONTACT PERSON (SECONDARY) DAYS: NAME(UST,FIRST) PHONE#WITH AREA CODE DAVIS: ME HAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE Nr: NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING a STREET ADDRESS -/Box to iMicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING ox STREET ADDRESS ✓BPx to mo,cate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL AGENCY Cl FEDERALAGENCY _ 13 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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&SIGNATURE) PATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION a AGENCY A FACILITY ID a N of TANKS at SITE ® 6�z3aI / I I 1 000 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE F WITH AREA CODE ulie PERMI MIMBEfl PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE j CENSUS TRACT(If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED pd a3 aV a YES NO � CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: \ THIS FORM MUST BE ACCOMPANIED BY AT LEAS OR MORE TANK PERMIT FORM 'B'APPLICATION(S), U THIS IS A CHANGE OF SITE INFORMATION ONLY. �`, /\