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STATE OF CALIFORNIA WATER RESOURCES CONTRO BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM _ o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION !l COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE J' 10 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE A CARE OF ADDRESS INFORMATION N � rQ ADDRESS $zM / (3�zo% NEARE FIT STREET ✓Box to indicate CIPARTNERSHIP ❑ STATE AGENCY Cjj IO ❑ CGRPORO[ON ❑ LOCAL ❑ �nEAAL AGENCY ❑ INDIVIDUAL ❑ CODUNNTYAGGENNCCY V L" GITY E STATCA 21P CODE SITE PH (Y1 AREA / µ ` TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BOx it INDIAN EPA ID # #of TANK's �AS STATION E] 3 FARM ❑ 5 OTHER TRUSTRESEYLANDS ❑ATION U, AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: N ME(LAST,FIRST) �� D P ONE N WITH AREA E DAYS. NAM[ ST,FIRST) PHO H WITH AREA CODE NIGHTS' NAME(LAST,F ST) ITONE N WITH AREA CODE NIGHTS ME(LAST,FIRST) PHON #WITH AREA CODE (� $ /4 g II. PROPERTY DIII INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME �� X30,111 CARED;)D SS INFORMATION MAIL/Iq�G/�Jor STREET ADDH S * ✓Box to Indicate 11 PARTNERSHIP LJSTATE-AGENCY //J\ ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDER -AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY DI KAMECJ ST14 ZIy0DZCS70� Z ,?v30/l III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDR SS INFORMATION ��P .I�GJtJCIe. r(/ MAIIIN or TREET AppRE55 ✓Box to'meicate ❑ PARTNERSHIP ❑ STATE-AGENCY S ❑ CORPORATION ❑ LOCAL-AGENCrH ❑ FEDERAL-A ENCY ❑ INDIVIDUAL ❑ COUNTY-AGEN CITY N E/A STATE ZIP D^ ONEITH AREA CODE S R f1 s IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. 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# JURISDICTION# AGENCY# FACILITY ID# S-5 q #of TANKS at SITE 3Cj OD I f lOO6 3 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE &It PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT N CODE CENSUS TRACT# SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DATE FLED f`( ''T A G YES NO 7 vz �V CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 2 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS HIS IS A CHANGE OF SITE 11VORMAII'lidlil ONLY. FORMA(3-2-88) � S DATA PROCESSING COPY