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77, STATE OF CALIFOAIA WATER RESOURCES COOL BOARD P f P� .YD FORM'A'-UNDERGROUND STORAGE TANK PROGRAM =� m R7:lr CILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE oay'. MARK ONLY ❑ ( NEW PERMIT ID 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM 7 PERMA TLY CLOSED SITE 21NTERIM PERMIT � q AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) a o F ILITY/SIT-E NAME / ^' ` � CARE OF ADD 5$INFORMATION ADDRESS IF a'/—IL I� EARESTC g$STREET ✓ to inai[ale ❑ PARTNERSHIP ❑ STATE AGENCY CORPORATION ❑ LOCAL ❑ FEDERAL AGENCY CO CITY NAMF, INOIVIDOAL ❑ COI 1Ni1'-AGENCY //////LL// STATE 21P CODF� PHO Eg_L 1EAREgLODE,/ 00 TYPE OF BUSINESS ` (JL/')b5 CA ]ice 2 DISTRIBUTOR 4 PR CESSOA ✓Box if INDIAN EPA IDN 1 GAS STATION 3 FARM 5 OTHER RESERVATIONar ❑ #of TANK's TRUST LANDS AT THIS SITE DL/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAV NAM (LAST,FIRST) PHO E N WITH AREA CODE DAYS: NAMEUST,FIRST( /)A �PHpNE p WITH AREA COPE C, -S-/OJ d NIGHTS. NAME(UREAT,FIRST) PHO E N WITH AREA CODE NIGHTS: NAME(LAST FIRST) It S PjQNE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME 14 Z CARE OF QDPRESS INFORMATION MAILINg{/STREET PRESS I/VI v. �� ✓ x to intlicale ❑ PARTNERSHIP 13STATE AGENCY r ( CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY CITY NAMEINDIVIDUAL ❑ COUNTY-AGENCY STATE P CODE�� PHONE WITH AREA CODE c,0060 I III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) S 04 NAME 5 /I � CARE OFATX INFORMATION MAILIN S RFT ADDRESS ✓ xIo'mtlicate ❑ PARTNERSHIP A CORPORATION ❑ LOCAL- 11 STATE-AGENCY AGENCY ❑ FEDERAL-AGENCY CITY NlTME� ❑ INDIVIDUAL ❑ COUNTYAGENCY STATE 21P CODE PHONE# WITH AREA CODE rA IV. LEGAL NOTIFICATION AND BILLING ADDRESS S A 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 C'O�)UTNT]Y# JURISDICTION# AGENCY# FACILITY 10 A, `--'c-`i--J #l7 V 7 of TANKS at SITE EEE; GGo CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME Z�PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED x 6 DAT FILE (J T YES NO C ECK# PERMIT AMOUNT SURC ARG AMOUNTr'6 FEE CODE RECEIPT# THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) 0 DATA PROCESSING COPY 0