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STATE OF CALIFOFRIA WATER RESOURCES COSO•OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM u " Si FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANG�SITE ON ❑ 7 PERMANENT ED SITE 1"a ONE ITEM ❑2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORURE IV I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME n CARE F ADDRESS I�FOR TION 1 Ccf rYl a,, 44' I u1 OSen Slee le ADDr � N REST CROSS STREET ✓Nw loiMkale Cl PARTNERSHIP ❑ STATE"AGENCY UJ • arch h Ldn e('J�� ❑ RATION AGENCY 11 FEDERAL"AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE c {c+an C (1�SaO� 229 95I �S30 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR I ✓Box if INDIAN EPA ID a RESE❑ 1 GAS STATION [:]3 FARM E; S<THER TRUSTVLANDS ATION Or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FI T) PHONE#WITH AREA CODE DAYS'. NAME(LASTILAST,F� PHONE#WITH AREA CODE NIGHTS: NAME(LA T,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME I S IDC CARE OF AD SNI WTION ^x1 Y i P FU r� �11't I�J�p�,f ll 6 MAILING or STREtT ADDRESS (/� ✓Box to incicalo E] PARTNERSHIP ClSTATE-AGENCY L LI oycap� ❑ CORPORATIONO LOCALCOUNAGENCY AGENCY ❑ FEDERAL-AGENCY INDCITY NAMJ�,(b/A STAT ZIP DE E#.WITH AREA CODE � PHON a 5do a, III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMEC LN 9f, S+o Ck4 rl CAREOFAD ESINFORMATI MAILU"IN'G or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY 4 25 GI �QY' - 1 - ❑ CORPORATION e0CAL-AGENGV ❑ FEDERAL-AGENCY CITY NAME Cl INDIVIDUAL ❑ COUNTY-AGENCY STA ZIP CODE PHONE#,WITH AREA CODE S+o n gSo1o�. ;Rog 9� q g.;,-1I 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. ©VIII. ❑ 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# JURISDICTION If AGENCY# j FACILITY ID At # 1 TANKS et SITE ll CURRENT LOCAL AGI FACILITY ID A!IV AJ \ ROVED BY - PHONE#WITHAREA CODE _PE YNUMBER PERMIT APPROVAL DATL- PERMIT EXPIRATION DATE LOCATION CODE CENSUSTCT SUPERVISO DI ICT CODE BUSINESS PLAN FILED DATE FILED 11�• Lev YES NO [:] i l - _CAO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: OD 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(3-2-88) DATA PROCESSING COPY .