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o_r 5E�'`iu�iti`.yF STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD u � i FORM `A': UNDERGROUND STORAGE TANK PROGRAM ="' ;p SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° s �911l ORN\P COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ffT5 CHANGE OF INFORMATION ❑ 7 P LY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S I..i 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) tT FACILITY/?s TE NAME �-, / �'L CARE Oa;S INFORMATION C �n{o'i✓ / v�L/CR o�Wn N i t ADDR ( � NEAF17T�TRZZEET ✓Bwl.,xi.le Cl PARTNERSHIP [ISTATE AGENCY ❑ "DUAL ❑ WUN AGENCY DER4L- NCY ❑ CORPORATION ❑ fACAL-AG ENCY CITY NAME ,J STATE ZIP ITE PH NE_p,WITH ODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID N of TANK'N a0 pY r RESERVATION or ❑ ,A / AT THIS SITE u ,'�/GGAS$TATION ❑3 FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAM (LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. N ME(LAST,FIRST) /PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMnATION &ADDRESS- (MUST BE COMPLETED) NAADD ESS M 0 ` CARE OF INFORMATION MAILING ar RE A DRE�`JQ ^ - Box la ale ❑ PARTNERSHIP ❑ STATE-AGENCY /[J�j ❑ CORPORATION O LOCAL-AGENCY EDER -AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY C � STATE ZIP C� �EN.WITH ARECODE M Ill. TANK OWNER INFORMATION 81 ADDRESS - (MUST BE COMPLETED) `T NAME Q A��-A�1 Lf CARE OF ADDRESS INFORMATION V (T V V MAILING or STREET ADDRESS ✓Box RATIte ❑ PARTNERSHIP CISTATE-AGENCY ❑ CORPORATION ORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNN-AGENCY CITY NAME STATE ZIP CODE PHONE N,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 M FACILITY ID% It of TANKS at SITE 00 1 ► = 0 10 CURRENT LOCAL AGENCY F ILITY IDN APPROVED BY N ME If PHONE N WITH AREA CODE ' PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION D LOCAXION ODE CENSUS TRAC N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F E '(, CC (' YES NO CHECK N PERMIT AMOUNT SURCHARGE A 0UNT FEE CODE RECEIPT N Yo / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-BS) • 1 N/ DATA PROCESSING COPY l