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STATE OF CALIFORN11 WATER I HESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE -7]�, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F"a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5 NJ I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) Fes► FACILITY/SITE NAME CARE OF ADDR S INFORMATION cLr 2�Ic QSh ADDRESS NEAREST CRO SSTREET ✓ lointlirak PARTNERSHIP ❑ STATE AGENCY flPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY INDmoUAL ❑ COUN7fAGENCY CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE Lo d� CA °IS a`4 0 204 33 aa3 TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID A M of TA RESERVATION or AT THIS SITE SITE ❑ 1 GAS STATION ❑ 3 FARM EE�l OTHER TRUST LANDS ❑ - EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE SSI-( 1' o_4a ems, Zo93332Z33 n6i NIGHTS YAME(LAST,FIRST) or PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE �1 S[-` fh �-- 2m e'l S_lq &2(,�C i II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAMECI ' IJ / C CARE OF ADDRESS INFORMATION W ry1Q MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP ElSTATE-AGENCY Kp / // �� M ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ` 4 l , 1 Ick i l 11INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAr' ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS N/Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,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. 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 M JURISDICTION R AGENCY R FACILITY ID M N of TANKS at SITE O 1 CA =-:;-s o v 1 a ® CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONOD CENSUSTRAACTX SUPERVISOR-DISTRICT CODE BUSINESS VES PLANFILED C's � DATE FILED Cc NO C ��. 00 CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k II IS FORM MUST BE ACCOMPANIED BY AT LEASWR MORE TANK PERMIT FORM 'B'APPLICATION(S), US THIS IS A CHANGE OF SITE INFORMATION ONLY. F RM A(3-2-88) DATA PROCESSING COPY '