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STATE OF CALIFORNIPow WATER RESOURCES CONTROLE90ARD " FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILIT /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 PER TLY CLOS 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 ADDRESS Xy /J NEARE/f/I�CROOSSS/STIR ET ✓BmbYMale 0 PARTHO W 0 SIATE46RI,Y -72 / !t/ Ov"�//� °o I"DUAnN °o `Ca AASEENCI ❑ RnERI1.AGENLY CITY NAME STATE 21P COD�� SITE PHONE p,WITH AREA CODE TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑/PROCESSOR ✓Box i11NDIAN EPA ID NESE9 /QN al9ANMa 3 ❑ i GAS STATION ❑ 3 FARM ❑ 5OTHEP TRUSTmLANDS Nor ❑ ATTHISSITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(UST.FIRST) PHONE N WITH AREA CODE S: NAME(LAST,FIRST) PHONE N WITH AREA CODE f} 10 _9 -333Rab u9-Yye-Iz'8- NIGHTS'. NAME(LAST,FIR S7, PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRV) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME el`_56/ Y lka - /olv� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS /nn� `/�6A oin irate ❑ PARTNERSHIP ❑ STATE-AGENCY / O ` 1/ D CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY // INDIVIDUAL 0 COUNTY-AGENCY CITU NAME 701V STATE „ ZIP CODE�� PMONQE p,WITH AREA COLIE III. TANK OWNER INFORMATION ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �J J/ MAILING or STREET AD ✓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 N,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. ❑ it. V III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME IPRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY4, JURISDICTION R AGENCY R FACILITY ID B R of TANKS N SITE " (�] 0 10 11 6 10 10 CURRENT LO ENCY FACILITY IDN APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CA E CENSUS TRACTIPSUPERVISOR•DISTTRRICTC BUSINESS PLAN FILED OAT%FILED Z 3 VES NO .Z CNECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS 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. -\/A`//FORMA(32-58)