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STATE OF CALIFORNIA- WATER RESOURCES CONTROL-BOARD °� "F FORM `A': UNDERGROUND STORAGE TANK PROGRAM �' SITE I G FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� I o COMPLETE THIS FORM FOR EACH FACILITY/SITE `^�,.oa„,> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FA IL2 SITE NAME CARE OF ADDRESS INFORMATION EUGL_ C Nem ADDR NEAREST CROSS STREET ✓ armutI ❑36?)D KA,S% h ❑ COWIMTON ❑ LPaaNAGHDCIP O�mmuA�raLVE ❑ IN AMAL ❑ C IkFr-AGENCY CITj?NE STATE CODE ITE P NE N,WITH AREA CODE l CA53�8 ZCA --414-1 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID It ESE ❑ I GAS STATION ❑ 3 FARM �5 OTHER TRUSTVATION LAND$of ❑ %Of TANSY AT TRIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) IaAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST FIRST) PHONE p WITH AREA CODE Y 15-4 E o 169 ZI�A 3�4 NI TS: NAME(LA FIR T) PHONE p WITH AREA CODE NIGHTS: NAM (LAST,FIRST PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME / JA E OF ADDRESS INFORMATION C S (� MAILING STR ADDRESS J ✓Box to intlicate ❑ PARTNERSHIP TATE AGENCY P ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME ST E ZIP CODE PHON p,WITH AREA CODE 96--b1z IL21421322 - 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAMECRE OF ADDRESS INFORMATION MAII_r, TRE T ADDRESS -/Box to intlicate ❑ PARTNERSHIP STATE-AGENCY ( 11 y ❑ CORPORATION El LOCAL 11-AGENCY FEDERAL-AGENCY l V ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY t;AM STATE ZIP CODE PHOI� WITH AREA CODE S 2 9 ZL IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II.� 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIN JURISDICTION% AGENCY% FACILITY ID If %af TANKS at SITE 39 0C) I ® ® dEl CURRENT LOCAL AGENCY FACILITY ID If APPROVED B ME PHONE%WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PEMIAITEXPIRATION DATE LLOrAnONCODE CENSUS TRACT% SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 23•S� Z3 YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) y DATA PROCESSING COPY �,