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STATE OF CALIFOR& WATER RESOURCES CONTROL BOARD FORM 'A': Qa ` �s UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ! COMPLETE THIS FORM FOR EACH FA LITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE PV ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓80,to i'E.Ie ❑ NERSHIP ❑ STATE AGENCY _ q/ S, ,/ v f./_ 1 ❑ CORPORATION LOCAL AGENCY ❑ FEDERAL AGENCY T Y _7 ST ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE on CA 9'5.3 Cao? S9 —o7/a3 TYPE OF BUSINESS: p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p ❑ 1 GAS STATION E] 3 FARM 2-5-OTHER REUSTVA ON ANDS or AT THHISIS SITE ❑ Mol TE p2 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(AST,FIRST) ZHOON�#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 219 - s4 NIGHTS'. NAME(AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(AST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREETADDR S ✓Box to intlicale ❑ PMI'TNERSHIP ❑ STATEAGENCY ❑ CORPORATION Ur LOCALAGENCY ❑ FEDERAL-AGENCY 3il &u . S 11INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE /? CA 9SaGL III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 4s .7l MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA BODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. Ill. ❑ 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 M AGENCY N FACILITY ID M It of TANKS at SITE 3 0 o v Cu LOCAL AGENCY FACILITY ID N APPROV PHONE N WITH AREA CODE PERMIT N L DAT PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT//CODE BUSINESS PLAN FILED DATE FILED of j 3 l� YES NO / CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# BY: ITHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORElANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS�CHANGE OF SITE INFORMATION 0' 11v'h_f' FORM A(3-2-RB) . -y /�/"1 DATA PROCESSING COPY