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QF STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE INFORMATION and/or PER z /o MIT APPLICATION �, to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT e5CHANGE OF INFORMATION 7 PERMANENTLY CLOSE SITE F'a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE '� N D7 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) m 00 FACILITY/$ITE NAME CARE OF ADDRESS INFORMATION La l^ 1 L7orre I 1 ADDRESS _ NEAREST CROSS STREET ✓13rOr Mule 0 PARTNERSHIP 0 STATEAGENCY ,53-3 3 E x a 5 I �. Z 0 CORPORATION 0 LOCA-AGENCY 0 FEDERALAGENCY ❑ INDIVIDUAL 0 COUNIKAGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE S�o c,K 4-w- CA 9 5 o s Cao9 a- ya TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID ft M of TANK'a ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESETRUSTYLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Co r ( Do rre l i MAILINGjr EETADOSRESS �I ✓Box to indlcWe 0 PARTNERSHIP 0 STATE-AGENCY / ) / n 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY VV 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE Cf� ! 2 5 CAO q 4'v- -,I y'a III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION s &+i-,e CLS o MAILING a,STREET ADDRESS pro � 'I ^-, ,� A, ✓Box to in0icate 0 PARTNERSHIP 0 STATE-AGENCY Y W,w, 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. Nr II. ❑ 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY IDM #of TANKS at SITE 10161 3 000 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER RMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D p D YES ❑ NO rL,71,21 �Q CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 ONLY. FORMA(3-2-SB) SDATA PROCESSING COPY