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i o STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD ..5E "" ' . FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : GCOMPLETE THIS FORM FOR EACH F CILITY/SITE "O MARK ONLY F-] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE Q ONE ITEM 1:1 2 INTERIM PERMIT 4 AMENDED PERMIT [:]6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) sW FACILITY/SITE NAME CARE OF ADDRESS INFORMATION r r U GlGvvl ..Y ADDRESS '"A / NEAREST CROSS STREET El 0 CORPORATION ❑ LOCAL AnERSHIP AGENCY ❑ FEDERALATE AGENCYGENCY as FENCY SW[ ❑ INDIVIDUAL Cl❑ COUNTY AGENCY CIN NAME C, � STATE ZIP CODE l SIT z GONE y�W H et'?^ f% CA J TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR I/Sox if INDIAN EPA ID N X of TANK's ❑ E] SOTHER TRUSTYLANDS of ❑ AT THIS SITE F-] 1 GAS STATION F-] 3 FARM ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE C ao9 j q Lte-a NIGHTS'. NAME ST.FIRSI PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE S d/✓h-le - II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) / NAME✓In.0 _ CARE OF ADDRESS INFORMATION 'G . 'Fdwp MAILING STFTADDR �� /N, -/Box to RATIle ❑ PARTNERSHIP ❑ STATEAGENCY 1j1� ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE Is 40 G/,C'4-vYv- _ A I Ia o III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION Cor L ` MAILINQ or STREE6bgPEPS ✓Bax to indicate Cl PARTNERSHIP Cl STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY O , j� ❑ INDIVIDUAL C COUNTY-AGENCY CITY NAME0 G /I STATE ZIP coD O PHONE k,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(7)BOK 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY41 JURISDICTION R AGENCY R FACILITY ID N N of TANKS at SITE km = = 16101 ) la iq 1010161,31 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE rCICE T ONDE CENSUSTRACTX SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3a � YES ❑ NO ❑ a a7K N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY THIS FORM MUST BE ACCOMPANIED BY AT LEAST 111 OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION40 Y. FORM A(3-2-88) 1�31 _9 1- DATA PROCESSING COPY