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STATE OF CALIFORNIV WATER RESOURCES CONTROROARD FORM IA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH ACILITY/SITE `'•'F�^=" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION cl \ 0m ADDRESS NEAREST CF1SS STREET I ✓BmWWM 0 PARTNEWIP 0 STATE AGENCY 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY 1Am plelilck QW 0 INDIhWAL Cl COUNTY AGENCY CITY NAME STATEIP CODE SITE PHONE N,WITH AREA CODE Oc on1 CA 5 05__ - — 6S90 TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID N RESERVATION or [:] If of TANK'F 1 GAS STATION FARM ❑ 5OTHER TRUST LANDS ATI SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE ;?I?- 6S=ym NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 1&- e,.j _7 65'- 11. PROPERTY OWNER IN ORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CNECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 R JURISDICTION S AGENCYIN FACILITY 10 R N of TANKS at SITE wii� 3 � CURRE LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DATE FILIP 2_3Z 2c "" YES ❑ NO 4411170 C E KN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY:c 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) • . v\ ' . �5 �