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STATE OF CALIFORNIA'S WATER RESOURCES CONTROL 9OARD SE" l�f FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ="° �, SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �° Z 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE °+4eavb�r FAF ONLY ❑ T NEW PERMIT ❑3 RENEWAL PERMIT 6 CHANGE OF INFORMATION F-�� ITEM ❑ PERMANEQNTLY CLOSEiD�SITE N ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE % ♦> W 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) p FACILITY/SITE NAME CARE OF DDRESS INFORMATION L_o_L v,J:L 5cu dant dd r1a AaQ �o ! l ADDRESS 1 ( rL NEAR STCROSS STREET /BMW le ❑ P IP ❑ STATE AGENCY lV LlJ MTIGN 11 LOCA 4AGENCY 11FEDEAAL.AGENCY CITU NAME OD ❑ INOMWAL ❑ E It WITH A STATE ZIP CODE _ SITE PHONE p,WITH AREA CODE TYPE OF BUSINESS: CA q 5 aoS a o 93 15CI ❑2 DISTRIBUTOR ❑/PROCESSOR ✓Box if INDIAN EPA ID N F-11 GAS STATION ❑3 FARM THER RESERVATION or - X of TANK# TRUST LANDS ❑ -- AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) &I PHONEp WITH AREA CODE NIGHTS: NA (LAST,FIRST) ' G] PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONEp WITH AREA CODE on a�xa0 11. PROPERTY OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION P'T�r MAILING or STREET ADDRESS 'Y'So.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY CITY NAME ❑ INDIVIDUAL ElCOUNTY-AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) NAME v CARE OF ADDRESS INFORMATION l fi'L.J� MAILING rSTREET ADDRESS �✓ xto indicate ❑PARTNERSHIP�. I .�I CORPORATION ❑ LOCAL-AGENCY - Cl FEDERAL-AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY c _ STATE ZIP CODE PHONEp,WITHAREACODE IV. LEGAL NOTIFICA N AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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# JURISDICTION If AGENCY# FACILITY IDX ® � X of TANKS at SITE LOLHEU:51 16= CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME / R r ' PHONE WITH AREA CODE PERMIT NUMBER `'I ERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPER TR-D TRICT CODE BUSINESS PLAN FILED q a 3 ' ]o ( DATE FILED Ov YES NO C' V CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# O BY: THIS FORM MUST BE ACCOMPANIED BY AT LEA10 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION FORM A(3-2-88) W DATA PROCESSING COPY