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STATE OF CALIFORNIk - WATER RESOURCES CONTROL'itOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE ED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESSNEAREST CROSS STREET ✓ftio ule 0 WINDOW 0 STATE AGENCY • D' /$� El At. LWINI 13 N Y AGENCY �f ❑ FEOEaAI AGDN.Y CITY NAME STATE ZIP CODESITE PHONE N,WITH AREA CODE :5 iib/.! CA 9 zo zoa) X62 -06 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P SSOR ✓Box it INDIAN EPA IO N RESERVATION or N of HIS SITE _ ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ElAT THIS STE L� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONEyyy+ITH AREA CODE DAYS: NAME(LASE FIRST) PHOyy�E N WITH AREA CODE mop roes/ (20�I) �f6Z-06r/a `�62- aS�{L7 NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITU NAME � STATE ZIP CODE �D� PHONE#,WITH AREA CODE Ill. TANK Y'c OWNERINFORMATION & ADDRESS- (MUST BECOMPLETED) NAMECARE OF ADDRESS INFORMATION MAILING orSTREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY PZ,> ' ,�j / !O 0 CORPORATION 0LOCAL-AGENCY 0FEDERAL-AGENCY /� fpL 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STAT ZIP CODE PHONE N,WITH AREA CODE 1c�`T r</ A- 95 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOE INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. IL ❑ Ill.❑ 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 N AGENCY R FACILITY ID IT M of TANKS N S1TE " 10 o l / 0 9 10 16)16 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE Z- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L E CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED23 - $v 3�3 YES ❑ NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: F" 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./ V FORMA(3-2-88)