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STATE OF CALIFORNIA WATER RESOURCES CONTROL OARD FORM `A': V. UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ ( NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE EWI I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) +c FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �C ,ca fp /Je pedS ADD)REyySS NEAREST CROSS STREET ✓Bo iMle ElPARTNERSHIP El STATE AGENCf N /dlOQ RPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY "ol El INDIVIDUAL ElCOUNTY-AGENCY CITU NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE lLL 1_/_I CA 5376 - /Z/S TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p 3 FARM 5 OTHER RESERVATION or #of TANK'a I GAS STATION ❑ ❑ ❑ TRUST LANDS ❑ �/�� 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 A/ G O 2- 7% NIGHTS: NAME(LAS TFIRST ONEp WITH AREA CODE NIGHTS. NAMEILA ,FIRST PHONE#WITHAREACGDE If. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CAREOFADDR SINFORMATION MAILING/�or STREET ADDRESS //ryyy ✓ to irtdi�le ❑ PAPARTNERSHIP ❑ STATEAGENCY (�� r CORPORATION ❑ LOCAL-AGEII ❑ FEDERAL AGENCY CITY NAME v ❑ INDIVIDUAL 11 COUNTY-AGENCY STATE ZIP CODE P NE#,WITHAREACODE Cif�vI-Al. _&f6 7�f Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 52147n C- Ak-7zr: MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCYCIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: D ❑ it. 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# #of TANKS at SITE 3 noiss / 00 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# & SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED r�y . 00Z YES NO'E S—p CHECK# PERMIT AMOUNT - SURCHARGE AMOUNT FEE CODE RECEIPT# BY: ORMTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION DATA PROCESSING COPY