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} STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD l? FORM A: UNDERGROUND STORAGE TANK PROGRAM u ° ; SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -m o COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 l YCLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CID FACILfTV/SRE NAME CARE OF ADDRESS INFORMATION d Ce d� s 7,�u�1< - ADDRESS //w NEAREST CROSS STREET Is O PART ERSNP ❑ SrATEl,GM o e COR Rf�L �� ❑ IIOFMM,LL� C3 WCKAGBOY ❑ SEXIM-AGDO CIN NAME STATE ZIP0 SITE O E p,WITH AREA CODE CA 3PH 376 TYPE BUSINESS: ❑ 2 DISTRBIITOR ❑4 PROCESkR ✓Box it INDIAN EPA ID a RESERVATION or #DI TANK's 1 Cv165TA710N ❑3 FARM ❑S OTHER TRUST LANDS ❑ ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LASTFIRST) / PHONEpWITH AREA CODE DAYS: NAME(LA�tFIRST) � - Zo9�ll3WITH�-AREA NIGHTS: NAM (LAST.A N PHONE p WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION CoRa4c, r�ct-ow 7/loyclL lH� MAILING or STREET ADDRESS T� x to indicate 11 PARTNERSHIP ❑ STATE-AGENCY O ( {III'L��L�Y��70� � CORPORATION 13LOCAL-AGENCY 11FEDERAL-AGENCY��,,,,ddd ••• ❑ INDIVIDUAL ❑ COUNTY-AGENCY CHV NAME _ ewil ttk STATE ZIP CODE —i PHONEp HAREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME S6tM..t ot CARE OF ADDRESS INFORMATION S MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY Cm 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: 1. II. ❑ IN.❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE le 00 v CURRENT LO AL AGENT 1LITY ID If ^ APPROVED BY NAME PHONE p WITH AREA CODE /(JYwV/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Lor-ATI r CENSUS TRACT G•m SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED p YES E] NO � - 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 ISA CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-110) �— DATA PROCESSING COPY