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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION T COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ T NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE IJ ONE REM ❑ Z INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Sb -4 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESSNEAREST CROSS STREET ✓PRbl&* ❑ PAPINEPSHP ❑ STATE AGENLY I S. L-'( doCOMORATON ElIOCAL-IGBILY O ROFPAL.AGENLY INOMDUAL ❑ COUNTYAGENLY CITYNAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE eAAXc x Cam CA 5623 7 TYPE OF BUSINESS. ❑p DISTRIBUTCA PROCESSOR '/Box if INDIAN EPA ID N •M TANK't ❑ 1 GAS STATION [—]3 FARM 5 OTHEfl TRUSTT LANDS RESERVATION Or El AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE e,m Frvr f o - -z 2- UKN NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA)ODE NIGHT NAME(LAST,FIRST) PHONE#WITH AREA CODE / p I. / {.1!k I0 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION � yno( 1 C MAILINGor STREET ADDRESS -/80.to i,dl..te ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY N� DIVIDUAL ❑ COUNTY-AGENCY CIN NAME C_k+ STgT� ZIP COD \ P;O�N.WITH%AREA CODE �— 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) 93 2'/'S NA CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ElSTATE-AGENCYC3CORPORATION ❑ LOCALAGENCY ❑ 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. ❑ If.❑ 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 M JURISDICTION X AGENCY S FACILITY ID K R of TANKS N SITE 1010 11 6000 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC ON CODE CENSUS TRACTItSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE�^ / oc3. CI�J yaU YES NO OI ` : CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: 1'1 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. I f�RM A(3-2-88) �r �,,,. DATA PROCESSING COPY `�