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STATE OF CALIFORNiP) WATER RESOURCES CONTROCARD FORM `A': ` UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w10 L `— ) COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT lJ 5 CHANGE OF INFORMATION ❑ 7_'�LOSEDSITE I--� j ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N I-` FACILITWSITE NAME CARE OS fkDDRESS INFORMATION ADDRESS � NEAREST ROSS STREET ✓Box P097IIO ❑ AATNEA EN ❑ STATE AGENCY ❑ CgNPORATION LOCALAGEEN ❑ FEOEAAbAGENLY ❑ INDIVIDUAL ❑ GJUNiRAGENCY CITY E A �.Q_ STATE ZIP COpp/ /' SITE HO E k ITHAREA CODE CA S S q1 I U TYPE OF BUSI NESS: EPA ID # ❑ 2 DISTRIBUTOR PROCESSOR ✓UOx if INDIAN RESERVATION or If of TANK's ❑ 1 GASSTATION ❑ 3FARM F�50THER TRUST LANDS ❑ 7Q ATTHISSITE D EMERGENCY CONTACT PERSON(PRIMARY) EMERGEhi CONTACT PERSON(SECONDARY) OAyS NAME(LAST,FIR T) Y b i PHONE p WITH AREA CODE DAYS. NA E LAST,FIRST) PHOIIIiIi WITH AREA CODE aA NIGHTS: NAME(LAST FIRST SP NE#WITH AREA CODE NIGHTS: ME(LAST,FIRST) P #WITH AREA CODE � II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAM CARE OFA RESS INFORMATION t�MDyA1 1 1071000 or REET ADDUSS ✓Do;to indicate ❑ PHEIRSHIP ElSTATE-AGENCY LlCORPORATION AGENCY ❑ FEDERAL-AGENCY [I INDIVIDUAL ❑ COUNTYAGENCY CITU NAME - 5� ZIP CODE� PHL ITHpREA�ODE o 101 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) ZV �lj fY/ NAMECApEO ADDRESS INFORMATION MAILING or STREET ADDRESS y� ,i✓-/BB-Am to indicate ❑QPARTNERSHIP ❑ STATEAGENCY /, �-1� ❑ CORPORATION U LOCAL AGENCY Cl FEDERALAGENCY • V •+/• ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME STATE ZIP CODE PHONE It WITH AREA);ODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS 7p1y S /V^A 1'I(—Oti/P1/ 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# AGENCYAI FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACIyITY ID k APPROVED BY NAME PHONE N WITH AREA CODE pC i S PERMIT NUMBER PERMIT APPROVAL DATE PdRialt EXPIRATION DATE LOCATION CODE CENSUS TRACT/N7�) SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Z�-�✓ YES Ej NO CHECK Al' PERMIT AMOUNT SURiiHAR6LlAMbUNT FEE CODE RECEIPT# BY: u f 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) ( \ y, � DATA PROCESSING COPY � J \