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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5` FORM 'A': UNDERGROUND STORAGE TANK PROGRAM p �a s7MARK FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETETHIS FORM FOR EACH FACILITY/SITE ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANITEM 2 INTERIM PERMIT q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ->r I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 16®_ FgCILITY/SITE NAMECARE OF ADDRESS INFORMATION n l ;DC f ADDRESS /' / NEAREST CROSS STREET ✓Bwroincticale ❑ PARTNERSPIP ❑ GTATEAGENLY N / //1/A /., 1^`G �I p ❑ CORPORATION ❑ LOCALAGEND ❑ FEGEMLAGENCI a C.( _(j` �J C.. ❑ INolvloua ❑ MUNT_AGENO' YI CITY NAME STATE ZIP CODE SITE PHON #,WITH AREA CODE W CA 6A 0 Cao9 4166-637-6 TYPE OF BUSINESS. ❑ 2DISTRIBUTOR ❑4PROCESSOR ✓Box if INDIAN EPA ID a A., ❑ IGAS STATION ❑3FARM ��S OTHER IF of TANK's TRUSTTYLANDS ATION or ❑ 'V orvE AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS- NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE Qrr Wra 6A `/(oG-637 NIGHTS'. NAME( B .FIRST) P ONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE e CL -F ,2t 7-0661 II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP 13 STATEAGENCY p 11 CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY GLQ )ap ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME ! I< STATE ZIP CODE PHONE p. THAREA CODE S V C 5 Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME eL44 r CARE OF ADDRESS INFORMATION PC C), MA ING or STRE ADDRESS -V Box to indicate 13 PARTNERSHIP 13STATE-AGENCY OR R El CORPORATION ElLOCAL-AGENCY ClFEDERAL-AGENCYII, l ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME C STATE ZIP CODE PHONE#,WITH AREA CODE Cl-4 20 `f(o(o-0375 IV. LEGAL NOTIFICATION AN6 BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID Al IF of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID Al APPROVED BY NAME PHONE#WITH AREA CODE n44 on PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE JLOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED Q / a6 0 / YES NO / CHECK# PERMI AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTk Y: 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, ORM A(3-2-BB) - J\ �l DATA PROCESSING COPY "1 1