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STATE OF CALIFORNIA WATER RESOURCESCONTROBOARD v FORM `A': UNDERGROUND STORAGE TANK PROGRAM V SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION :off o COMPLETE THIS FORM FOR EACH FACILITY/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 —I N I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) v FACILITY SITE NAME CARE OF ADDRESS INFORMATION 0 ADDRESS NEAREST CROSS STREET ✓5000wlute ❑ PARTNERSHIP ❑ STATE AGENCY NA IlS . ❑,�, � �M➢ON El LOCAL AGENCY CI FEDERAL AGENCY IVINwl"UAL ❑ COUNT(AGENCY CITY NAME STATE ZI CODE SITE PHONE p,WITH AREA CODE CA J� u TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Bax it INDIAN EPA ID N RESEp of TANK's a OT ❑ I GASSTATION ❑ 3 FARM HER TRUSTVLANDS ATION o ❑ f{/ Ykt— AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST( PHONE#WITH AREA CODE Silvioao �i4-5- NIGHTS' A S .FI T) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 1 G h cL1T �. MAILING or STREET ADORE ✓Box ind;c Io ❑ PARTNERSHIP ❑ STATEAGENCY �1 �n ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY P Ct DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAtfi ZIP C0 PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILINGor STREET ADDRESS ✓Box to,,dcate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE L C q 5 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE Du 10 1 W 1 0 600 CURRENT LO L AGENCY FACIE YID N APPROVED BY NAME PHONE N WITH AREA CODE OLS❑ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA(/TI�)ON CODE CENSUS TRACT (j'�'NSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED v 1__Q '3 1 v Ll a 3 YES NO CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. FORM AA(�(3--2-88) / //�y�y � • DATA PROCESSING COPY � • ' `/\)