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STATE OF CALIFORNIP WATER RESOURCES CONTROROARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION JH- er * 1qSSa(*, ry ADDRESS _ NEAREST CROSS STREET ✓'Co"P RATIO ❑ LOCAL PARTNERSHIP ❑ FEDERAL AGENCY ;�F7 �a �• ✓� l Sf� Fi1 berms ❑ INNwloua O LOCAL AGENCY Cr ❑ F9eant cFAcv CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE W SfoG CA S vaQ - l3 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID If ]I / ❑ GAS STATION ❑ 3FARM ❑THEA TRUSTYATION orLANDSo ❑ �✓ o Yv`— AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE At WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE e i ty zeh Ron, C,g09 9 - 13Yf5 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE Same- (209)41-7?- 373,' II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION crm c� ,Sl MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION sum ,e ces sl'-6e MAILING or STREET ADDRESS ✓Box to'odioate Cl PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE If,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. 9it. ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE o 6)1 /= 1010101 / 1 CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE#WITH AREA CODE C PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT It SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED L./ 3i Q YES NO / 0 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At BY: I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM rB'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. A(3-288) -\ DATA PROCESSING COPY