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STATE OF CALIFORNO WATER RESOURCES CONTR BOARD FORM 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 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N n r CL gr en s NEAREST CROSS STREET ✓ aM D 1 .91P 0 STATE ADDRESS O WRPORI0 I.004AO uACR 'a ( -5 - k cl ❑ lxomouuL ❑ caxn AGENCY CITY NAME /'�/J, STATE ZIP COT,_ SITE PHONE N,WITH AREA CODE Q� /J/� TYPE OF BUSINESS: 2 DISTRIBUTOR Lj 4 PROCESSOR ✓Box it INDIAN EPA ID N _ M of TANK'N F-11 GAS STATION ❑3 FAN El5 OTHER TTRUSTYATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE C ro(x-er-t rcooGrject 20 �I64- NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION C rOGker ✓Box to indicate 0 PARTNERSHIP - 0 STATE AGENCY MAILING or STREET ADDRESS7 F 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAMEn ' ^^ STATE ZIPCO �� PMONE M.WITM ARTA CODE 6R6� III. TANK OWNER INFORMA✓TION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION lY/ W� ✓� MAILING or STREET ADDRESS ✓Box to ieoicele 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. E] II. E] III. El THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION E AGENCY M FACILITY ID B N of TANKS at SITE 3 [�] [�] o rs = r 101010 17 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE I-I Ery P_i l�2_ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATI CO CENSU SUPERVIS R-DISTR T CODE BUSINESS PLAN FILED DATE FILED/] YES NO ❑ a�—I—7 o CHECK N PER1111141110UNT SURCHA MOUNT FEE CODE RECEIPT N BY: pff ��F(IS VRM MUST BE ACCOWA D BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. F (3-2-88) (J