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fFPu¢ a55- Ilp -�r STATE OF CALIFORNP WATER RESOURCES CONTR*OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLYl❑ 1 NEW PERMIT F__] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El PERMANENTLY CLOSED SITE ONE ITEM ti/ ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE/INFORMATION &ADDRESS — (MUST BE COMPLETED) ° S/�CILITY/SITE NAME E OF ADDRESS INFORMATIO ADDRESS KAREST CROSS STREET 6 Sox%inalcele ARTNERi ❑ STATE AGENCY N ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY (� 'va.Lr '' '' ` /a f>L ❑ INDIVIDUAL ❑ CDUNTY-AGENCY00 IW NAME 61STATE P CO ITE PHONE N,WITH AREA CODE CD 6 j2/4-0 CA V1/ TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax it INDIAN EPA ID N N of TANK'# ❑ 7 GAB STATION ❑ 3 FARM �s oTBeRTRUSRESETYLANDS or F-1 �3 U n K/1ATION 0Lv 11 AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) MERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE 6 iRilL I .k 1 2v r �3 C� g�1 GHTS NAME(LAST,FIRST) PHnnO N WpITH AREAx'COJ/DE NIGHTS: NAME(LAST,FIRST) J/P[H�yONE N WITH AREA CODE fl II. PROPERTY 6WNEFf INFORMATION & ADDRESS — (MUST BE COMPLETED) ME ' C E OF ADDRESS INFORMATION / LING.,STREET ADDRESS ✓Box to md1cate ❑ PARTNERSHIP ❑ STATE-AGENCY Z/ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY NAME TE CODE E N,WITH AREA CODE IVA 'fit Z( v/ III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME E OF ADDRESS INFORMATION ING or STREET ADDRESS �� ✓Box Io.i irate LlPARTNERSHIP ❑ STATE-AGENCY (� T' ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY En AME TE XCODE NE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS v CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. if. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY �tn JURISDICTION N AGENCY N 35 FACILITY IDN= = U U 1 1 6 RR T LOCAL AGENCY FACILITY IDN OVIED BY NAME PHONE N WITH AREA CODE /epoi MIT NUMBER IT APPROVAL DATE E MIT EXPIRATION DA E CODE US TRACT M i1UPERvi a-DISTRICT CODE BUSINESS PLAN FILED ,1 LED I V YES NO /� —/S—'PERMIT AMOUNT SURCHARGEAMOUNT 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. FORM A(3-2-88) • DATA PROCESSING COle