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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ,z`��°��• FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � - COMPLETE THIS FORM FOR EACH FACILITY/SITE `'L FORAI MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ZRI55-CHANGE OF INFORMATION TLY CLOSED SITE ONE ITEM 112 INTERIM PERMIT ❑ 4 AMENDED PERMIT 1:16 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME z^/ CARE OF ADORES INFORMATION GL L OA v 10 0, ADDRESS NEAREST ROSS S EET ❑ PARTNERSHIP El STATE-AGE10� ❑ ` L ❑ RDERAI AGEC TIGIN Y // / g ❑ COlNY GEN CITY NAME STATE ZIP CODESITE PHONE N,WITH AR CODE CA S G Zoe!- 9 yzz TYPE OF SINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N I GAS STATION [—]3 FARM ❑5 OTHER TRUST LANDS ar ❑ AT THIS SITE y EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) V� P;ONFO#AREA CODE DAYI NAME(LAST,FIRyST) ,V tjeO N M f —Z N WITH AREA CODE )Iq NIGHTS: NAME(LAST,FIRST) PHONE d 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 HC�_lb of Go A-tt�j MAILING or STREET AD ESS x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 1 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATEZIP CODE PHONE N WITH AREA CODE /J �! �-- 9 I d Ill. TANK OWNER INFORMATION ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADO SS INFORMATION �/✓vY�. �`tel MAILING or STREET ADDRESS W4.x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY . ❑ FEDERAL-AGENCY ❑ 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY* FACILITY ID# #of TANKS at SITE ® L 10 1 OF-If o :��1 o 16 lol CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAMEPT 1p E N WITH AREA CODE Zr -r G� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE i LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ID e) YES [:] NO ❑ CHECK t PERMIT AMOUNT SURCHARGE AMOUNT FEE CODERECEIPT N THIS FORM MUST BE ACCOMPANIED BY AT LEAST/1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UN�SS THIS IS A CHANGE OF SITE IN ORMATION ONLY. FORM A(3-2-88) Y