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OF STATE OF CALIFORNIA WATER RESOURCES CONTROL bUARD WP' �Sa FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - 1 11.0 COMPLETE THIS FORM FOR EACH FACILITY/SITE FORN P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 21 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IV ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O l r I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Opo FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS �J NEAREST CROSS STREET ✓_Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY O '`G/_� I ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE S o�kTn i.� CA Cr Z-05 CZE) o 2-,Lf J TYPE of BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # ❑ ❑ RESERVATION RUSTY ANI DS or ❑ #of TANK'S "GAS STATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(AST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE CA-►PR 6,9Z '. 2 q I NIGHTS: NAME(AST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(AST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION X20 6EO-r- MAILING or STREET ADDRESS ,11 x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY P O ,J Q,O I'l�fj// LT CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 44&�QD C,A Gl 32-F,Z__ III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION I,eo S.Ez-I6Sot\I MAILING or STREET ADDRESS ��✓B3�x to indicate El PARTNERSHIP ElSTATE-AGENCY L CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY / �0 7�O ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE /ZW 69AL) 7 3 Z IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ If. 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# AGENCY# FACILITYrID# #of TANKS at SITE 1014 J l 131 CURRENT LOCAL A ENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE ��DZi PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 1 LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED YES ❑ NO ❑ ///'?/ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: r� \\THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)-D MORE T"i PERMIT FORM `B'APPLICATION(S), UNLEQR THIS IS a I'HANGE OF SITE INFORMATION ONLY.0 FORM A(3-2-88) DATA PROCESSING COPY