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STATS OF CALIFORNIA WATER RESOURCES CONTROAARD f5ti �0x; FBF FORM `A': u_ >. UNDERGROUND STORAGE TANK PROGRAM Y 'tea SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY . NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE ONE ITEM f' t ` INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE L12 rZ' I. FACILITY/SITE INFORMATION & ADDRESS -- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS.INFORMATION _2 ADDRESS NEAREST CROSS STREET ✓Box a Wicate ❑ PARTNERSHIP ❑ STATE AGENCY yr „_, i �. ❑ CORPORATION 1:1 LOCAL-AGENCY 11FEDERAL-AGENCYVvCl INDIVIDUAL ❑ COUNPY.AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE /L. 74-y� CA � L 1 ,ZOZ— S2-3 U PTYPE SINESS, EPA ID N 2 DISTRIBUTOR 4 PROCESSOR ✓BoxifINDIANRESERVATION or N of TANK's AS STATION © 3 FARM 5 OTHER TRUST LANDS D AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) p PHONE III W714 AREA CODE (rv'!� ' fv M -4 0 -711 ��-�► t NIGHTS: NAME(LAST.FIRW__ PHONE N WITH AREA CODE NIGHTS: NAME(LAS 4RST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGFNCY ❑ CORPORATION ❑ LOCAL-AGENCY C] FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#•WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME T'7 � 11 CARE OF AIWIIESS INFORMA N MAILING or STREET ADDRESS 1 _ } 0 ✓Box to indicate ❑ PORTNERSHIP ❑ STATE-AGENCY •�� !1'f ❑ CORPORATION ElLOCAL-AGENCY Cl FEDERAL-AGENCY fFYiY>✓Sr 11 11 �y1/ e Cl INDIVIDUAL ❑ COUNTY-AGE Y CRN NAMES STATjr'T + Z }DE- � L 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. 1:1 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 [NUMBER JURISDICTION# AGENCY N FACILITY ID N �j N of TANKS at SITE '' Q �' C O U 3 ENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE PERMIT APPR VAL ID PERMIT EXPIRATION DATE 1q, CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI/LED F f� -' I! IG+ YES !d0 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:� ` /e-_ HANGE OF SITE INFORMATION ONLY. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)DR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A C RM A(3-2-ae)