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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': ;moo Z UNDERGROUND STORAGE TANK PROGRAM SITEF FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY IV] 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 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 00 FACILITY/SITE NAM r^ CARE OF ADD/AEEES�1S.S INFORMATION 23 - Al, ' L ADDRESS �� 1 /�. _ ±NEAT OSS BT�iEET V CORPi RATIOute ❑ LOCAL AGEN ❑ FEDER A AGENC� ///Lj\/xET 1- COAPOAAiION ❑ PARTNE SHIP ❑ STATEA GENCY�iNMK ❑ INOIVIOUAL O COUNTYAGENCY CITY NAME ZI CODE S TEPH E#,WITH AREA CODE III S �o �v°I qy -ozorI TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓BOX If INDIAN EPA ID # �! RESERVATION or #of TANK'# U ' GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME I¢AST,FIRST( PHONE#WITH AREA CODE DAV . AME(FAST.FIRST) PHONE 411TH AREA CODE ts FS. I�ECS - 11 � � Sa NIGHTS: NAMS,(L ST. IRST) PHONE#WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PHONE WITH AREA CODE S F 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) zNAM CARE OFA RESS INFORMATION Wmas� �• N MAILING or STREET ADDRESS I/B"to,nd,cate 0 PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION 0 LOCAL-AGENCY ERA AGENCY it ma&h ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP ODE PHONE .WITH AREA CODE Lott' C� d'L z q -Lvtl 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF AOPRESS INFORMATION MAILING or STREET AD DRESS N✓,8ox .coat. 0 PARTNERSHIP 0 STATEAGENCY ' H CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL 0 COUNTYAGENCY CITY NAME 5 fyTE ZIP CODE�� ^� ITH AREA CODE 1 IV. LEGAL NOTIFICATION AND BILLING ADDRESS C CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ If. 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID M #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APP OV�D BY N ME PHONE#WITH AREA CODE S-0 - PERMIT NUMBER PERMIT APPROVAL T PER IT EXPIRATION DATE lb LCHECK# DE CENSUS TRACT# UPE OR-DISTRICT CODE BUSINES,PES N FILED NO DATE FILED yl� 7±PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 111111 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIONON RM A(3-2-88) • DATA PROCESSING COPY