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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u �" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SI7E N ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION _ ADDRESS Q NEARESt OSS STREET ✓fttNxdlasle 13 PARTNERSHIP ElSTATEAGENCY A/O N• O� `� OA IRA ON 11 LOX AGENCY 11FEDERAL-AGENCYM611N t VNDNIDUAL ❑ 001N1Y-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE dC Hoij TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID a 0 of TANKS ❑ I GAS STATION ❑ 3 FARM IL75 OTHER TRUSTYATION LANDS of ❑ CAC 000 AT THIS SITE•i EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY=)(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ,� no� 209- 6 0978' UkN NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE KIN 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME �! CARE OF ADDRESS INFORMATION W MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. II. ❑ 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# AGENCY# FACILITY ID#_ II of TANK 1 CU LOCAL AGENCY FACILITY 10 k 1/ Y E APPROVED BY NAME PHONE N WITH AREA CODE Ln_- Pultrwitm i PERIVIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOARISTRICT CODE I BUSINESS PLAN FILED DATE FILED 3,TO YES NO 6� CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPr# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST GR MORE TANK PERMIT FO RM 'B'APPUCATION(S), U S THIS IS A CHANGE OF SITE INFORMATION ON FORM Y. FORM A(3 ) ✓/ ' DATA PROCESSING COPY Nltl/