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STATE OF CALIFORNIA. WATER RESOURCES CONTROvp ARD FORM ' Al: UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE RED I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION /�A K CAA wAsf/ XA-t N-r kNuTso nl ADDRESS AVE. NEAREST CROSS STREET ✓Barin Mme Cl PARTNERSHIP Cl STATE AGENCY 601 E• 1tI N ak A /LI °O INOPA`ON °° �"cE- ° BE°Bu`-AGwcr CITY NAME STATE ZIP CODE SITE PHONE M,WITH AREA CODE STEI-KTbt4 CA 2-6142_ (Coot) 7,542 B IND AN EPA ION TYPE OFBUSINESS: ATION ❑ 3 DASTRIBIROR El <PROCESSOR ESERVATION or ❑ Nal TANK1 ❑ 5 OTHER TRUST LA ANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE rAT14Y KAluTso (za0 'lK- z5`I2 PETr 6/A.Aa4Wo (zea) 5,z3- g'oo 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 viwr466 CA4 u- 45W PETC e4.4MI5.4tlov MAILING of STREET ADDRESS -/Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY ° CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY ZOZO s- ,4NOIFOAD A.vP. 0 INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE DI)ESTo G.4 �j$350 (t CA) Sz3- g�eo III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION v t N-r4 E cAA lvA_40 MAILING or STREET ADDRESS / ✓Box to IYdicale 0 PARTNERSHIP 0 STATE-AGENCY �I .. ,1 . I /�n �VG . ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY -OZO S-rAM I i=04D 0 INDIVIDUAL 0 COUNTY-AGENCY Cltt NAME STATE ZIP CODE PHONE X,WITH AREA CODE /440OF-57-0 c-4 RS 3�o zoo) S23 - 8/00 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. Ell THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRU CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R AGENCY N FACILITY IDM N W TANKS M SITE 0 0 L t g 3 3 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE Si4Adu*- (go PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED Of Z3. s V 37-3 YES NO CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: ,O.-r 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° FORM A(3-2-813)