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M TATE O F CALI FO WATER RESOURCES CONIRROC BOARD S FORM `A': Wf aim UNDERGROUND STORAGE TANK PROGRAM Yo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE - MARK ONLY❑ 1 EW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT El 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Oa , 14 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION FACILITY ID # ii / SS a ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY I 1 1] ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS O / /,/ �y 1 //f! j g r � /�. i� ❑ INDIVIDUAL ❑ COUNTY -AGENCY NEAREST CROSS STREET,✓.,, C� � �+ �R indicate ❑ PARTNERSHIP ❑ STATE -AGENCY LYCORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME PHONE #, WITH AREA CODE STATCA ZIP C� PERMIT NUMBER SITE PHONE #, WITH AREA CODE C PERMIT EXPIRATION DATE 01 o TYPE OF USINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN RESERVATION or EPA ID # # of TANK's 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ / DI? �- BUSINESS PLAN FILED AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE R. W. McEa r I a rs e 69 15 It 5- Al, ne NIGHTS: NAME (LAST, FIRST) PHONE # W H AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE �- 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/ ]lox to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CORPORATION - ElLOCAL-AGENCY ElFEDERAL-AGENCY/�� Q� /1/, / ryvIF%'1 8 1 ✓ . _soD INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE LlJ yt o f r_ C4.1 '/1(q15)1q5-7&7i III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Si Me- 2S Pro >e0 FACILITY ID # MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY I 1 1] ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY 10101/1/17[�] [(D1016131 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, 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: 1. ❑ 11. 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 I nf`AI ArrFlUi I ICF Il l v COUNTY # JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE [H�] I 1 1] [:[ I—] 10101/1/17[�] [(D1016131 CURRENT LOCAL AGENCY FACILITY ID # APPROVEDME PHONE k WITH AREA CODE �� un; ori a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUP VISOR -DISTRICT CODE BUSINESS PLAN FILED DATE FILED d / YES NO E] CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # 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 ONLY. FORM A (3-2-88) DATA PROCESSING COPY ""\S DO