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STATE OF CALIFORNMI WATER RESOURCES CONTRIOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACY FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT w 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bmbianle ❑ PARTNUMP 0 STATE-AGDO 0 CGRPONATION ❑ LOCk-AGENCY 0 FWk-AGM ❑ INDNIDUN 0 COUNTY-AGENCf CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE PF�C. Crz CA 95=231 TYPE OF BUSINESS: ❑2 DISTRIBUTOR 7 4 PROCESSOR ✓Boz if INDIAN EPA ID x ❑ 1 GAS STATION ❑3 FAEN ❑5 OTHER RESERTRUSTYLANDS ATIONor ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE N WITH AREA CDDE ST an. �f ZZ N q 05) 7 N15 NIGHTS: NAME(LAST,FIRST) 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 54� N MAILING a STREET ADDRESS ✓So.to indicale 0 PARTNERSHIP 0 STATE-AGENCY nn��'A It /p 11 CORPORATION 13LOCAL-AGENCY ❑ FEDERAL-AGENCY 222— E It P1, ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMESTATE ZIP CODE PHONE N,WITH AREA CODE s4 �� C74 5 02 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sq,,-, doom &L" Ll)l MAILING a STREETAbDRESS ✓Boz to ietlicate ❑ PARTNERSHIP 0 STATE-AGENCY 2 13 CORPORATION 1:1 LOCAL-AGENCY ❑ FEDERAL-AGENCY 'e-, ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMESTATE ZIPCODE PHONE N,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. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY M FACILITY ID P R of TANKS At SITE ® O_ 1 2= CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE r-16yr?199 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENWS TRACT SUPERVISOR--7DISTRICT CODE BUSINESS PLAN FILED DATE FILED liq 2 3 , YES ❑ NO CHECKN f PERMIT AMOUNT 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 ONL RMA(3-2-BB)