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STATE OF CALIFORNIA' WATER RESOURCES CONTROL HOARD t s FORM A : UNDERGROUND STORAGE TANK PROGRAM �o SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m l C, COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWALPERMIT v 5 CHANGE OF INFORMATION7 PE TLY CLOSED SITE ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE l./ I I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE , CARE OF ADDRESS INFORMATION owJ! u i M NEAREST CROSS STREET ✓ eitlizk ❑ PARTNERSHIP ❑ STATE AGENC/ N ADDRESS CORPoMTIDN ❑ LOCAL-AGENCf ❑ FEDERAL AGENCY INDMDUAL ❑ WUNIYAGENCY CITU NAME .sl/lov STATCA ZI9sZO P CODE / SITE PHONE ,WITH AREA TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑/ SSOR `✓CBoox if INDIAN EPA ID IT (// •/n/`n' It of TTANK'sRESE 7F2 ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSTVATION LANDS uI 5 ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE Jr WITH AREA ODE DAYS'. NAME(LAST,FIRST) PHONE A WITH AREA CODE /&II 7 ,9 �S'G v4 (//C NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 2aleA&ZSE& IW-7- K II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) G// NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS.) xto indicala ❑ PARTNERSHIP ❑ STATE-AGENCY O /��✓�� ❑ INDIVIDUAL El 1:1 LOCAL-AGENCY❑ COUNTY AGENCY ❑ FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 61111-4 t- U7nr-�'�1 (rt l MAILING or STREETI ADDRESS - Iy 'n ox to indicate ❑ PARTNERSHIP 11 STATE-AGENCYIff CORPORATION 13 LOCAL-AGENCY 11 FEDERAL-AGENCY wA ❑ COUNTY-AGENCY GIN NAME wk STATE Zg � PHONE k,WI'H CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS /7� CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 III LOCAL AGENCY USE ONLY COUNTY if JURISDICTION M AGENCY X FACILITY ID 9 N of TANKS at SITE U / o Fj 1010101,71 CURRENT LOCAL AGENCY FACILITY I# VED BY NAME PHONE 0WITH AREA CODE PERMIT NUMBER S G•—RMIT APPROVAL ATE PERMIT EXPIRATION DATE 9111,4 ES OQE CENSUSTRACTN 42-0 U 'R lOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED ''l//,� 1, (/ �N YES NO ��OU ✓" PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: 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) i DATA PROCESSING COPY ""`