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STATE OF CALIFORNIA -" WATER RESOURCESCONTROLSOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a �a SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z IG I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION L e _.Service P.) ADORES S o� NEAREST CROS STRI=E� ✓ IIi IATG ❑ PARTNERSIF ❑ STATE (� .+.,7 5 1. � 1940 GI�,TLVm K r Q Iw�N DNALCN ❑ CONry AGENC! ❑ FEDERAL CITY NAME S c/ rV '— STATE ZIP CODE a' SITE PHONE p.WITH AREA CODE 00 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 OCESSOR -/Box if INDIAN EPA ID # ' Cs� pl ❑ ❑ V TRUSTYLANDS o ❑ Ne' �`4 #of TANK'S / o 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE wovLSe Bruce laa4 ?ie_ NIGHTS: NAME(L%&,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE ,S rd m e Caoq y-73-36060, II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION e / u L G MAILING or STREET ADDRESS^ ,1 ✓ x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY /� C r e Q,.// ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 1� G ,`L.0 r LJ INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME � SC 4 ZIP 5� O PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BEC NAME CARE OF ADDRESS INFORMATION O MALI or STREET A ESS V Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY r ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY AME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 29 11. ❑ If. ❑ 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 COUNTY# JURISDICTION If AGENCY* FACILITY ID# #of TANKS at SITE 101611 goo I ci 01 / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA CODE Z 729 3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L E CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED air F0 YES NOEj J 76 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'Be APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1 fF�QRM A(3-2-85) N-�' DATA PROCESSING COPY -� ��