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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD A FORM A: UNDERGROUND STORAGE TANK PROGRAM Z SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to l/ COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER NTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE _4 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 00 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION GIAA N ADDRESS yy/J c/ NEAREST CROSS STdR�EET/ ` ✓B> Irak ❑ PARTNERSHIP ❑ STATE (J (// /� V✓/ I /��F' 1946 �G /7W(/ 1NEItDUA"[ON ❑ COIN AGENCY ❑ FEI1FAAl AGENLI' CITY NAME �i// STATE ZIP CO E_ -�/ SITE PHjjNE It,WITy AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F__] 4 PROCESSOR '/Box Boz iI INDIAN EPA ID # �I�/`�Y /IW/1 N/ o1 TAANNICS I ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTILATIONANDS or El THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE X WITH AREA CODE DAYS. NAME(LAST ,FIRST) PHONE If WITH AREA CODE Do N —9 RBl NIGHTS: NAME(LAST.FIRS , ^ PHONE 0 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE V, A IL PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION V MA i N FSR- CO �r►G MAILING or STREET ADDRESS ^/ ✓Box to"'dicate ❑ PARTNERSHIP 11STATE-AGENCY V0 ` ❑ CORPORATION 1: LOCAL-AGENCY [IFEDERAL-AGENCY ( D{/ V ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME 1 STATE - ZIP CODES PHONE k ITTHf CODE .JGiY(AM, 1 (//fin. 9 Y(,�. d Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME C 0".&en u < CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS J J ✓Bax tomclicate ❑ PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS F�7rI CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L 1:1 11. ULJ Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'SNAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY 10 8 N of TANKS at SITE EH = = 1010 1 11-07[RZI1010 lo I I CURRENT LOCAL AGENCY FA.WI�IDA APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER (Drr( PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECKO DE CENSUS TRACT D 8UPERVI80R-DISTRICT CODE BUSINES YPLAN FILED NO ❑ DATE FILED / PERMIT AMOUNT SURCHARGE'I�AM•ITO/Uv'NT) FEE CODE RECEIPT0 BY:4w &NTHIS 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. M A 13-2-SS) � DATA PROCESSING COPY