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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM o SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION CCOMPLETE THIS FORM FOR EACH FACILITY/SITE \!FoaN i F ARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANE�L_,)Fy,�LOSED SITE "a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE _ �I I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) -�1 FACILI ITE NAME��` CARE 0 ADDRESS INFORMATION ADDRESS .J NLE`ARR1ESjT/`CIROSSS EET ✓ to indicate El PARTNERSHIP ❑ STATE-AGENCY ' 10( Z� CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY �/• ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE P NE#,WITH AREA CODE 21 CA e7S ;TYPE OF SINESS: F—] 2 DISTRIBUTOR F—] 4 PROCESSOR ✓Box if INDIAN EPA ID # RESERVATION or p #of TANK's 1 GAS STATION ❑ /3 FARM ❑ 5 OTHER TRUST LANDS ❑ l/ AT THIS SITE 03 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY4 NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. N ME(LAST,FIRST) PHON #WITH AREA CODE coq) �,. S 1; A NIGHTS. NAME( S . ) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHON it WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �z J r is I � MAILING or S REET ADDRESS ✓,�x to indicate El PARTNERSHIP ElSTATE-AGENCY 1.i'CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME P STATE JZIP CODE /, / �� W AREAJOiE3 ll III. TANK OWNER IN RMATION & ADDRESS — (MUST BE CJOMPLETED)s!/ C of L/ 6 ,J NAME CARE OFADDRESS INFORMATION NAME Cit Cit /L) A MAILING or S4REET ADDRESS ` �✓ x to indicate ElPARTNERSHIP ElSTATE-AGENCY Ld>CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY . ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAtdE STATE ZIP CODE HONE ITH AREA CODE IV. LEGAL N&TIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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# h FACILITY ID# #of TANKS at SITE t) y' CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EX IRAT ON DATE LOCATION ODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO ld r� CHECk# PE AMOUNT SURCHARGE AM UNT FEE CODE RECEIPT# BY: ITHIS FORM MUST BE.ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY, �� FORM A(3-2-88) DATA PROCESSING COPY