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STATE OF CALIFORNIAWATER RESOURCES CONTRODdOARD 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 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 141lt-PA4194rD ADDRESS NEAREST CROSS STREET ✓Bmbi'drsk ❑ PVRWRW ❑ 9AUAGEN0 'L67 t4. ❑ COW MTON ❑ LOGLAGBA,Y ❑ ROENALAGENCY ❑ INArDUAL ❑ COIMIIYAwE CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA Zoa 1-1-L- 3A-'6 TYPE OF BUSINESS. ❑ 2 DI IBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID p ❑ 1 GAS STATION 3 FgRM ❑ 5 OTHER RESERTRUST VLANDS ATION dr ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE IE vTN zva) 31NW-61-4 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION /A,c- v^�l�CG6n/Z 2 Y 4A' MAILING or STREET ADDRESS /'�� ✓Box to iodic e 13 PARTNERSHIP ❑ STATE-AGENCY 1:1 LOCAL-AGENCY 0 Z 4455- �l(�G/Y �11� ❑ INDIVIDUALION 0 COUNTY-AGENCY FEDERAL-AGENCY CI NAME STATE ZIP CODE PHONE p,WITH AREA CODE 5 G/l/i— 1 C?157 (Zc�Lkl31=3�s� 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION F 1z,2 ,eo r F 4A'! T'pes MAILING or STREET ADDRESS ✓Box to indicale 13 PARTNERSHIP ❑ STATE-AGENCY �y j E C / 11CORPORATION O LOCAL-AGENCY 11FEDERAL-AGENCYZ//p CL� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE S�G+�`rbe�J C_-4-- yrs Z�*� 431-3�{STS IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L Ll 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 R JURISDICTION If AGENCY B FACILITY ID It Sof TANKS N SITE " O O 3 ,0 1 1' c� CURRENT LOCAL AGENCY FAG LITY 10# APPROVED BY NAME PHONE#WITH AREA CODE V1 7— PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOGTON CODE CENSUSTR • SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO ❑ DATE FILED a YES CHEC-KK# 4PERMMIT AMOUNTSURCHARGESURC3HARGGElAAMMOUNT 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-BBI I \