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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD St's 'fie W i FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Si7 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -m COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 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 zioe He V ADDRESS NEAREST CROSS STREET ✓Bos loiMG@ ❑ PARTNERSHIP ❑ STAR AGENCY ❑ nON ❑ Lom AGENa ❑ FEDERAL-AGDO GNIDIAL ❑ WUNTYAGENCY CITY NAME STATE ZIP ODE 91TE PHONE N,WITH AREA CODE CA 5 TYPE OF BUSINESS. p2 IBUTOR ❑4PROCESSOR ✓Box it INDIAN EPA IDN _ ,1 o1 TANKY ❑ 1 GASSTATION 3 FARM ❑ 5 OTHEfl RESERVATION TRUST LANDS or 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 N WITH AREA CODE 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 MAILING or STREET ADDR %/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY C �/) ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE C -,5 3(� olOq S`t - 777 III. TANK OWNER I FORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sots a,-a- MAILING or STREET ADDRESS ✓Box to'odlcate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRBSB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ u-M 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 N JURISDICTION R AGENCY* FACILITY ID K R of TANKS at SITE CURRENT L CAL AGENCY FACILITY ID 4 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT ON CODE CENSUS TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Cow YES NO [ /�- CHECK N 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 ON FORM A(3-2-88) •