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STATE OF CALIFORN&� WATER RESOURCES CONTROL BOARD i w FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITEDC FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ro�rii CHANGE OF INFORMATION ❑ 7 PERM L ED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILI /SITE NAME /� C EOF ADDRF�SS NFORMATION d Q(.l. t�2. ADDRESS NE RE ST CROSS STREET ✓RO,Io irA.Il ❑ PARTNERSHIP ❑ STATE AGENCY �. ,❑ RPORAT10N 11 LOCAL AGENCY El FEDERAL AGENCY O p� INDIVIDUAL ❑ COUNTY AGENCY 10V5.CITYNAt'0 STATCA ZIP CODE � IT PH�NE p,WITH A CODE TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA,ItD/p [� �'(fM� N of TANK's //��`�(+'fJ' ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ATION G ❑ AT THIS SITE (J 1 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS'. NAM (LAST,FIRST) PHON p WITH AREA CODE 16 � NIGHTS NAME(LAST,FIRST PHONE k WITH AREA CODE NIGHTS. ME(LAST,FIRST) PH 4 WITH AREA CODE S fl o9 3 - L2f�' ,A �1 II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NA CARE OF ROSS INFORMATION MAILING or STREET AV ✓B to intlicate 11 PARTNERSHIP ❑ STATE-AGENCY /Tw CORPORATION 13LOCAL AGENCY ❑ FEDERAL-AGENCY (� A INDIVIDUAL ❑ COUNTY-AGENCY CITY ATE ZIP CODE HONE .WITH AREA CODE NiLeo 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME 114 ff I CARE OF ADDRESS INFORMATION I � MAILING or STREET ADDRESS ✓Box tomicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME f STATE ZIP CODE PHONE p.WITH AREA CODE I. IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Pr I. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID It #of TANKS at SITE n] op zZs' C) 01010 1 / CURRENT LE L AGENCY FACILITY 10# APPROVED BY NAME _ f PHONE*WITH AREA CODE PERMIT NUMBER OQIjJ` PERMIT APPROVAL DATE ,VIoKPEEER-MIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FIL O Z �J :F-Qu q! YES NO 1$/i4 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) \A DATA PROCESSING COPY `.