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.� �.. STATE OF CALIFORNIP WATER RESOURCES CONTROILRD FORM A : UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION zI o COMPLETE THIS FORM FOR EACHCILITY/SITE .pk MARK ONLY ❑ I W PERMIT E] 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE05-7 1I IV I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) W O FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Seg E ' vt wet-ber ADD�R.^E/SSS 7 /� ,,�� NEAREST CROSS STREET ✓ oiM-le D PARTNERSHIP D STATE-AGENCY `^ - 1 WCliVbt , F O �� VOUALIGN 13 COUNTYAGENCY LOCALAGENCY 13 fFDFAAL-AGENCY CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE C_k t5�� CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHEA TRUST LANDS TION or ❑ X of TANK's AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE W 1`s Cao�j - NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE S II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADD ✓Box to indicate D PARTNERSHIP ❑ STATE-AGENCY D CORPORATION D LOCALAGENCY ❑ FEDERAL-AGENCY D INDIVIDUAL D COUNTYAGENCY CITY NAME STA --)6RP/�— PyONE TH AREACODE III. TANK OWNER INFORMATION 81 ADDRESS— (MUST BE COMPLETED) l/ ( NAME CARE OF ADDRESS INFORMATION Gt .S MAILING or STREET ADDRESS ✓Rox tolnoicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERALAGENCY D INDIVIDUAL D COUNTY'AGENCY CIT'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. t>d 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION R AGENCY k FACILITY ID k k of TANKS at SITE ail 77o Oool CURRENT LOCAL AGENCY FACILITY IOM APPR ED BY AME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DAM a 3 ► ( LOCATION CODE CENSUS TRACT M SUP RVISOR-DISTRICT CODE BUSINESS ES N FILE DATE FILED 9 3 a ❑ NO ❑ CHI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTa I I gy:: 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-BS) • DATA PROCESSING COPY