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STATE OF CALIFORNIA WATER RESOURCES CONTRBOARD P \S{ FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITEF FACILITY/SITE, INFORMATION and/or PER PPLICATION / " 2 COMPLETE THIS FORM FOR EACH TY/SITE " MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1fr5 CHANGE OF INFORMATION ❑ 7 PERMANENT YCLOSEDSITE 1�T ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �� I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION Ila n4 l`7 S y ADDRESS NEAREST CROSS STREET ✓ male 0 PARTNERSHIP 0 STATE AGENCY �t� ❑ ItioviDUALIGN 0 COUNWAAGFNC ❑ FEDERALAGENCY CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE S C r4/0 CA 9S3(d TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a R of TANK's ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYIANDS ATION or ❑ Y� AT THIS SITE C/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE ,7 o4 n vk e 2 g,-/-- t-o - 3 -- 6//�3 NIGHTS'. NAME(HAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Srr-5 MAILING or STREET ADDRESS ✓Be.to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S u —v e_ R S -7— MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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. EP'll. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID M M of TANKS at SITE 3 1 D 1,0 C RENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE N WITH AREA CODE D'a_ PERMIT NUMB PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRA�C"jT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED \� CHECK# PERMIT AMOUNT SURCHARGE OUNT FEE CODE YES [:]RECEIPTf NO ❑ BY. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) • • DATA PROCESSING COPY