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STATE OF CALIFORNIP WATER RESOURCES CONTROARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM At SITE Ea FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION rr] COMPLETE THIS FORM FOR EACH FA ILITY/SITE ''OR-"-�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANE SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 10 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION cu 111Ma P W-,Y-q Jf ry ADDRESS NEARE TCROB REET ✓Boe to mGicale ❑ PARTNERS D STATE-AGEN'Y C ❑ CORPORATION ❑ L AGENCY D EECEAALAGENIX d .( D INDIVIDUAL 0",AGENCY CITY NAMEC^/ STATE ZIP CODE SIT PHONE 4,WITH AREA CODE 1� CA 95 Fs - 30 TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR '/Box it INDIAN EPA ID # RESERVATION orl ',,,,, n If of TANK's E] 1 GAS STATION [_] 3 FARM HER TRUSTLANDS ❑ ^�/T W 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 p WITH AREA CODE l�.v✓ �9 335 �A 723 s13�S NIGHTS'. NAM (LAST,FIRST) HON pWITH AREA CODE NIGHTS'. NAME(LAST, RST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ��,� )) CARE OF ADDRESSS IN/F;ORRMATION 4f /' ol MAILING or STREET ADDRES0 ✓Bax to,nd,c to PARTNERSHIP D STATEAGENCY D CORPORATION D D FEDERAL-AGENCY alr2 c lQ� ❑ INDIVIDUAL 6AELrOUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE S-I—ac t2 CA- — y5,6f-33-!2 III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box tor,d,cate D PARTNERSHIP ❑ STATE-AGENCY D CORPORATION D LOCALAGENCY ❑ FEDERAL-AGENCY D INDIVIDUAL D 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. ❑ I. 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# JURISDICTION 1t AGENCY R FACILITY ID• #o1 TANKS at SITE C) I cd / If C) ac) 13 CURRENT LOI AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER /`U` C S9 PERMIT APPROVAL D TE PERMI EXPIRATION DATE LCKECK# ODE CENSUS TRACT M SUPER SOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Z YES ❑ NO �PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 FORM A(3-2-88) 411 DATA PROCESSING COPY