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� or o I STATE OF CALIFOR WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o COMPLETE THIS FORM FOR EACH FACILITY/SITE ""•�^=�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑6 CHANGE OFINFORMATION PERMANENTLY CLOSED SITE F"A' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) co OD FACILITY/SRE NAME % CARE OF ADDRESS INFORMATION Kct Iuamck i:c�cA !J Ka i s et- ADDRESS 00 �^ V ^/ L NEAREST CROSS STREET ✓ la iao" ❑ PARTNERSHIP ❑ STATE AGENCY tq/j (� • 1 2 V � Mp�UAI� O CCWNIYAGENC ❑ �IUI-AGENCY CITY NAM - STATE ZIP CODE SITE PH NE#,WITH AREA CODE /IJG�P►j CA 7-36 2oq _jga TYPE OF BUSINESS: ❑2 D16TRIBUTDR ❑�4�PROCESSOR ✓Box if INDIAN EPA ID aESERa of TANK's ❑ 1 GAS STATION ❑3FARM 1&7OTHER TRUSTVLANDS ATION or ❑ /`/V AT THIS SITED 1 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: (NAME(LAST,FIRST) PHEATH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH ARCODE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE tSer Row gCr7-3950 II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) CARE OF ADDRESS INFORMGTION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY I6O �• {AV( 49CORPORATION 11LOCAL-AGENCY El /�f�/ ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE I ZIPCODEHONE N,WITH AREA CODE L_wo E N 4C.4 452P 3 6 uxp III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME S µ& As AR DUB CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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. ❑ 11.vIII.❑ 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 K JURISDICTION k AGENCY# FACILITY ID# If of TANKS at SITE MT 10 10 1 -a I 1 1010011 CURRENT LOCAL AGENCY FACT ITYID# APPROVED 8Y NAME PHONE WITH AREA CODE SF_ I PERMNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DI TRICT CODE BUSINESS PLAN FILED GATE FILED VES NO /� C 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, ORM A(3-2-88) ✓✓// 0 DATA PROCESSING COPY •