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STATE OF CALIFO%IA WATER RESOURCES C•FORM `A': ROL BOARD s< SITE UNDERGROUND STORAGE TANK PROGRAM e FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m COMPLETE THIS FORM FOR EACH FACILITY/SITEo z 1C MARK ONLY El NEW PERMIT IF. ONE xN`" ONE ITEM ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ P RMANEN CLOSED SITE 1, FACILITY/SITE INFORMATION &ADDRESS — ❑s TEMPORARY SITE CLOSURE ~ N FACIE /SIT NAME (MUST BE COMPLETED) ICA &J, CARE OF DRESS INFORMATION y� ADDRES ) � n N /O 2� Cd'dV �'G�i NEAREST CROSS STREET CITY NAME �&�L ! */Box to MW 0 PARTNERSHIP C] STATE/ A I�� ,/ 0 CORPOPATION 0 LOCAL AGENCY ERAL A NGL' QV STATE INONIDUAL 0 COUNTY_AGENCY ❑ --�4 ROCESSOR ✓ CA ZI�(�C/OIr PH NE u,WITH AREA CgOE TYPE OF BUSINESS. I `C�'E P 6 (A 2 DISTRIBUTOR � Box if EPA ID a 6 ❑ I GAS STATION ❑3 FARM 5 OTHER RESERVATION or EMERGENCY CONTACT PERSON(PRIMARY) TRUST LANDS ❑ �� #o1 TANK's A7 THIS SITE 191 DAYS: NAME(LAST.FIR�RT) EMERGENCY CONTACT PERSON(SECONDARY) �•. e PH E N WITH AREA CODE DAYS: NA E(LAST,FIRST) NIGHTS: N (LAST,LAST,FIRST/L ✓ A PHONE N WITH AREA CODE 7`y P NE#WI H AREA CODE NIGHTS: NAME(LAST,FIRST) II. PRO ERTY OWNER INFORMATION &ADDRESS — PH E#WITHAREAcoDE SA NAME (MUST BE COMPLETED) CAREOF REQS INFORMATION MAILING TRE ET ADDRESS �s ✓ OF to intlicale 0 PARTNERSHIP CITY NAME Cl CORPORATION 0 LOCAL-AGENCY 0 STATE-AGENCY 0 INDIVIDUAL ❑ COUNTY- FEDER -AG NCV STATE AGENCY ZIP CODE PHONE ITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — Z yb b — Z NAME (MUST BE COMPLETED) ACARE OF ADDRESS INFORMATION MAILING or S BEET ADDRESS '/BOX to intlicale ❑ PARTNERSHIP CITY NAME 0 CORPORATION Cl LOCALAGENCY0 STATE-AGENCY 0 INDIVIDUAL 0 COUNTY- ClFEDERAL-AGENCY STATE AGENCY ZIP CODE PHONE p,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS "CHECK (1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD AF USED FOR BOTH LEGAL NOTIFICATION AND BILLING I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATUREI DATE LOCAL AGENCY USE ONLY coulvry x I JURISDICTION# AGENCY# � � FACILITY/ISD# �)#of TANKS al SITE ali CURRENT LOCAL AGENCY FACILITY IDN I� r( !APP OVED BY gvME^ PHONE#WITH AREA CODE PERMIT NUMBER J PERMIT APPROVAL GATE L/ lam PERMIT EXPIRATION DAZE LOCATION CODE CENSUS TRACT N /SAN g QA SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED 11// lJ// + '0u — GATE FILED CHECK# PERMIT AMOUNT YES ❑ NO [3-' /D �6 SURCHARGE AMOUNT FEE CODERECEIPT ! a # BY: 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 FORMA(3-2-88) 0 DATA PROCESSING COPY 0