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/ STATE OF CALIFORNIH WATER RESOURCESCONTROBOARDs FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 01/ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT F–] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PE NENTLY G,^,"''TE ONE ITEM ❑ 2INTERIM PERMIT ❑ N AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION E- F)db Nntjp-:- N ADDRESS NEAREST GROSS STREET ✓ ala raaale 0 PARTNERSHIP 0 STATE AGENU C.TT - cowoRAnox O IocA1_ACENcv ❑ EEOERA.AGEN9 WA� womouAl ❑ couxrvacEND' STATE ZIP CODE TE PH NE#,WITH AREA CODE CIN NAM TYPE USINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box,I INDIAN EPA ID a pot TANK's 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST FIRST) PHONE a WITH AREA CODE � 2�C NIGHTS'. NAME(LA .FIRST) Y PHONE#WITHEA ARCODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE -71&,3q—/Z/ II. PROPERTY OWNER IN ORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION -z MAILING Or STREET ADDRESS ✓�� RCy'C#R-IO indicate ❑ PARTNERSHIP ❑ STATE-AGENCY LLY(:ORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAM STATE ZIP CODE /^ HONE a,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME y CARE OF ADDRESS INF ATION MAILING OI STREET ADDRESS � ✓�P�-IPORATIle 0 PARTNERSHIP 0 STATE FEDERAGENCY L-AGENCY B3� 10Odicatn 0 LOCAL PARTNERSHIP 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CI NAME STATE ZIIPP C"ODE DRONER WITH AREAC OE AT ZIP IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ 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 d SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY N FACILITY ID# #of TANKS&I SITE IfRl �] O O O151 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT #CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILD YES E] NO E] _ Z3. CHECK# PERMIT AMOUNT SURCHARGE AM UNT FEE CODE RECEIPT N 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. FORM A(3-2-88) —. ('/ -�' 1 /\ , —>,0 _ DATA PROCESSING COPY J