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STATE OF CALIFORNO WATER RESOURCESCONTRAOARD '` > FORM 'A': UNDERGROUND STORAGE TANK PROGRAM aI �) z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT215 CHANGE OF INFORMATION ❑ 7 PERMAN SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 56 a I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) NW )i FACILITY/SITE NAME - I CARE O 4ORESS INFORMATION 1, ADDRESS , �� 1! N RN�S/TC7G SS STREET ✓2mmiro®Ie ❑ FWR4FB9 ❑ STAMACDC Qvrti.c. Cl00WOUTON 0 LOCALCM EA P .,YiBN,Y Cl INDNIDIN 0 COUNIY AGENCY 'K?/ CITY NAME STATE tV ZIP Gc_QE SITE PHO E N II HpCODE �� CA qS Zaa .3Z - TYPE OF BUSINESS: ❑ y DISTRIBUTOR ❑ 1 PROCESSOR ✓Box if INDIAN EPA 10 x A of TANK's ❑ I GAS STATION ❑ 7 FARM 5 OTHER TRUSTVLANDS ATION w 1:1 AT TNIB SITE Q a EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME( ST FIRST) HONE N WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE 9 WITH AREA CODE ul � lr_ r � qo S NIGHTS: NA E FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) P 0 E N WITH AREA CODE S S A S"A II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) CARA FADORESS INFORMATION NAM W& / MAILING o THEW ADDR SS /' ✓Baa to intlicate ❑ PARTNERSHIP 0 STATE-AGENCY (/ I � !\J r7F 0 CORPORATION Cl LOCAL-AGENCY EOERAL- ENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE n,WITH AREA CODE GDG/ C SZYo 2ve -1310 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION i I MAILING or STREET ADDRESS ✓Boa to indicate Cl PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY j CITY NAME STATE ZIP CODE PHONE I,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 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 M JURISDICTION Al AGENCY S FACILITY ID M I of TANKS at SITE ET l 3 DOO CURRENT �K67AGENCY/F�LITY IDI APPROVED BY NAME/ / PHONE 11 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE /,�/F/!) 3PERRMIT EXPIRATION DATE L N CODE CE-N7SUSTRAACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDZ_ Z� p (J YES � NO 3 /3 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS BY: i 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 ONLY. FORMA(3-2-88) \ 0 DATA PROCESSING COPY k.