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y<'au pf tM FATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD .. JRM 'A': UNDERGROUND STORAGE TANK PROGRAM =� r �� Z al FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ic C9L,f ORM.P C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY [if1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE � ONE ITEM ❑ 2 INTERIM ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE © I r\3 I. FACILITY/SITE INFORMATION 8 ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF DRESS IN FOR TION O r to Sac e--6,_ f' .Z C_ /n Q ADD ESS NEA EST CROSS STREET Dhow ❑ PARTNERSHIP ❑ STATE AGENCY o�D O Fa FRc/►Ior� �Ir eL� ❑ INOMWAI PORATION O BOG NC ❑ EOEA -AGENCY CITY NAME STATE ZIP ODE SITE PHONE# WITH AREA CODE S c Kd-�, L� CA a - TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑d PROCESSOR '/Box if INDIAN EPA IO n /7/may, A-1 N of TANK'Y ❑ I GAS STATION ❑3 FARM OTHER TRUSTVATION LANDS or ❑ / w ' — AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE IF WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE gift h'trM 12 NIGHTS. NAME( ST, )RST) d3 (a PHONE M WITH AREA CODE NIGHTS'. NAME ILA .FIRST) PHO 14e TH AREA CODE - 5- II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION L- MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY IJ f� ❑ C ORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY (�I Ali L DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE S o III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �S r MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY O CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl 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: 1. ❑ it. ❑ 111. ❑ 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 B AGENCY R FACILITY ID k S of TANKS BI SITE D 16 1 /=s O 12510 CURRENT LOCAL AGENCY FACILITY ID M APPROVE BY AM PHONE N WITH AREA CODE S PERMIT NUMBER PERM/:R/aLDATE PERMIT/EXPIRATION DA ^ IM LOCATION CODE CENSUSTRACTT�y# � SUPERVISOR-DISTRICT CODE BUSINESS P NFIL DATE FILED 16� D a3 x 4V a I YES ❑ NO CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k 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) J „� DATA PROCESSING COPY 1./`