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v STATE OF CALIFORNI0 WATER RESOURCES CONTRO410ARD s OF f W: FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE /� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -,m l I o C� COMPLETE THIS FORM FOR EACH FACILIT SITE oa," MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE sO a) 00 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION w s co u7�rrrofili/e N14 ADDRESS c NEAREST CROSS STREETiw PARTNERSHIP ❑ STATE AGEN9 �`jY LOCAL-AGDO ❑ FEDERAL-AGENCY UCWNTFAGFN9 CITY NAME STATE ZIP CONE p,WITH AREA CODE SAV crE /-v L CA � gY�' G ybTYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 P ESSOR ✓Boz AINDIAN EPA ID a RESER❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSTYLANDS ATION or ❑ / If of TANK's t11ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(IAST,FIRST) PHONE ItWITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE uS o/t otr'9- YYIl'(oY6 Sly NIGHTS: NAME(LAST,FI ST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE Sp, _/& 3-101f1 S��J II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME 5/,g CARE OF ADDRESS INFORMATION 2 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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: I. 11. ❑ 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 N JURISDICTION X AGENCY B FACILITY ID k A of TANKS AI SITE 3qEEI 10101 / o 0 1 0 1 o 1 a CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION COODE CENSUS TRACT N /, SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED �� D( �� . {/ 3a..� YES � NO CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p BY: n 1, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLEQQ THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-68) 0 DATA PROCESSING COPY •