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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD W. FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ate" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; ,o COMPLETE THIS FORM FOR EACH FACILITY/SITE �'A�Foay1P MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENT Y CLOSED SITE I--L ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 0000 FACILITY/SITE NAME 1 D �!^ S CARE OF ADDRESS INFORMr cAe ADDRESS `I N.,l NEAREST CROSS STREETaLI IIARTNERH ❑ STATE AGENCYNaO ❑ POCALAGENCY ❑ FEDERAL AGENCY k-- ❑ DVDUAL 11 COUNTY- AGENCY CITY NAME STATE ZIP CODE SITE PHONE It.WITH AREA CODE TYPE OF BUSINESS: ❑2 01 OR ❑ 4 PROCESSOR I '/Box i,INDIAN EPA ID # ' / ❑ 1 GAS STATION 3FARM ❑ 5OTHER TRUSTTSERVATION VLANDS Or ❑ t"L[L AT THIS SITE O/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST)) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE J NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME Dellk CARE OF ADDRESS INFORMATION J erytj MAILING Or STREET ADDRESS ✓Box to 'cate ❑ PARTNERSHIP ❑ STATE-AGENCY /J3 2p ❑ ORATION EDLOCAL-AGENCY 11 FEDERAL-AGENCY 3 C rs NOMDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE C4 ucc-1 Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION IS/10- Z11 MAILING or STREET ADDRESS ✓Boxt icate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ POEATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE q,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. ❑ I. 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 IN SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION M AGENCY M FACILITY ID# #o,TANKS at SITE i = = 1 1 411 2- 121 o o v I / CURRENT LOC AGENCYFACILITY ID N APPROVED BY NAME PHONE Jr WITH AREA CODE YS(-/\T 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# E CENSUS TRACT ^# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 O'3 3a� YES ❑ NO ❑ C blval PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: ' 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 FORM A(3-2-88) DATA PROCESSING COPY