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STATE OF CALIFORNIA WATER RESOURCES CONTROL oOARD /ZE'•� .lhf. W�. -A FORM `A': 49 � UNDERGROUND STORAGE TANK PROGRAM =�° "°m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE C9„!FoaN P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Z5 CHANGE OF INFORMATION ERMA TLY OSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1 9 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) r FACILITY/SITE NAME CARE OF ADDRESS INFORMATION t7G protI 4,etooja ADDRESS NEAREST CROSS STREET ✓Box toirdicale ❑ PARTNERSHIP ❑ STATE-AGENCY v �[/� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMESTATE ZIP CODE SITE PHONE#,WITH AREA CODE _577-or—9- z) CA 4,43-6397 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID k ❑ [:] RESERVATION or G Not �f 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS ❑ ��.� &6 Z y D 7_J �ATTHISSISTE 4� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE lz-K ly r=tq NIt (�9)s4 - 836,F NIGHTS: NAME(LAST.FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 7-141W ls?_4e4e_T-00 D MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ,// ,p I/I� ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY 5"30 /7 9I�Y -� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE 511beA7o^1 G./.4-- q Zo III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION E 57-v C, Toy.( I°�cv,�i7 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY . x GD ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE Siwe r_ tl C �ISZo IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. E?r� 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY FPERMITNUMBER JURISDICTION If AGENCY N FACILITY ID k If of TANKS at SITE o t l AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ' CENSUS TRACT MSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO ❑ D E FILEYES PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k 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(3-2-68)