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OF STATE OF CALIFORA WATER RESOURCES CONTROL BOARD �` r 'A � � FORM A: UNDERGROUND STORAGE TANK PROGRAM m SITE FACILITY/SITE, INFORMATION anchor PERMIT APPLICATION ' S G COMPLETE THIS FORM FOR EACH FACILITY/SITE c941Fa—"'� ARK ONLY F-11 NEW PERMIT El 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ME ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ $ TEMPORARY SITE CLOSURE Q I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE Of ADDRESS INFORMATION lk r 8' ADDRESS NEAREST CROSS STREET ✓85R b indicak ❑ PARTNERSHIP ❑ STATE-AGENCY 1 7 - Al' l W1,5b W� ❑ CORPpRAT14N ❑ COUNTY-AGEN Cl FEOEAAL-AGENCY T/L ❑ INDNIOUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE I SITE PHONE N,WITH AREA CODE TYPE/OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Bax if INDIAN EPA ID N k of TANK's RESE1=J ' STATION ❑ 3 FARM ❑ 5 OTHER TRUSRVA�T QS or AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE"WITH AREA DE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE G 4 ?14.0 Zo�()gNI- b G tfo NL lo►-E Ld 4k Z'V4 /-2Z' NIGHTS: NAME ILAST,FIRST) PHONE 4 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 CPHvN P91,nhl6' MAIL4NG or STREET ADDRESS / J / v/Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY El LOCAL-AGENCY Ili�,� IV �iJ 11154p ❑ C DIV DUALI©N ❑ COUNTY AGENCY Cl FEDERAL-AGENCY CITY NAME STATE ZIP ODE PHONE M,WITH AREA CODE 5c-kYb ( i Ryas-S zy III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRES ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY / Cl CORPORATION El LOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE q,WITH AREA CODE T-0 IJ Ck 76 705Zoq) 441- zz6 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. IIL THIS FORM NAS 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 rPERMITNUMBER JURISDICTION N AGENCY ff FACILITY ID N M of TANKS at SITE bO D C� Od O �AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE 1A r N r 7 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT N SUPERVISOR-DI TRICT CODE BUSINESS PIAN FILED Ng DATEFIL PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: ,� THIS FORM MUST BE ACCOMPANIED BY AT LEAST R MORE TANK PERMIT FORM 'B'APPLICATIofi UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. r I FORM A(3-2-88) '