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STATE OF CALIFORMA WATER RESOURCES CON L BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM �o Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 --l-j COMPLETE THIS FORM FOR EACH FACILITY/SITE "1OR MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONPERMANENTLY CLOSED SITE 1"'a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE A W I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N CJi FACILITY/SITE NAMEII � CARE OF ADDRESS INFORMATION 1 Lc r2, - Q ADDRESS NEARESTCROSS STREET ✓So rdute ElPARTNERSHIP [I FATE-AGENCY HI I r 1 p .A� WORATION ❑ LOCAL�AGENGY ❑ FEDERAL AGENCY G 1 ✓IC V �T —fir ❑ INDNIOUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE sto c ch ,-, CA 8520 Z a09 9,4 c, 63a TYPE OF BUSINESS: DISTRIBUTOR ❑ 4PROCESSOR Box if INDIAN EPA ID a RESERVATION or K of TANK'e ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ �� AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST( PHONE k WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o�JSTRREEET ADDRESS V/ o -1 STATEAGENCY IP ION El LOCAL-AGENCYFEDERAL AGENCY Y Y, ❑ INDIVIDUAL [I COUNTY AGENCY CITY NAME STAT ZIP 4E PHONE p,WITH AREA CODE Ln �� S261 Sa fI Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME � ^^ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE 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. ❑ II. ffl III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,)S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION M AGENCY k FACILITY ID S K of TANKS at SITE 10101F= IQ1010101_ CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE M WITH AREA CODE k S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DI Tfg CODE BUSINESS PLAN FILED ❑ DATE f ED mt ON ((^J( VES NO x 01 CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a 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 A(3-2-88) 40 0 DATA PROCESSING COPY