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STATE OF CALIF RNUA- WATER RESOURCES CONTROL BOARD res. FORM `A': UNDERGROUND STORAGE TANK PROGRAM = " SITE AGILITY/SITE, INFORMATION and/or PERMIT APPLICATI } r' COMPLETE THIS FORM FOR EACH CILITY/SITE MARKONLY F-11 NEWPERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1 A E N ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE V I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) V 28 1 t71 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION '✓I .1 EAi I ATE07A R65. ete fe a 4/F•!J/I/pj��✓✓' pR HegL7 ADDRESS ' I T y� NEAREST CROSS STRE ✓Bolamil le l!?PARTNR& U#T GENC/ H O O S . C O L J D W 1 ✓ J ❑ NDNIDUALION ❑ COUNW AGENN ❑ FED IAGENC CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE C CA 93 7Z AioAv- TYPE OF BUSINESS: 'El 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N of TANK's ❑ ® ❑ TRUSTYATION LANDS D ❑ N�'V r® W n AT THIS SITE �( 1 GAS STATION 3 FARM 5 OTHER EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE DAYS' NAME(LAST,FIRST) PHONE N WITH AREA CODE Pete ►- fe a Cae 83s-�83 t Ra »+ond d,<fe a (2c?),i 3936 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME OARS F ADDRESS INFORMATION nn TEGA1 ROS , etc Arte a /�.wk.ftNIIIo, MAILING or STREET ADDRESS ✓Box to lntllcate LaI'iSAR NERSHIP ❑ STATE-AGENCY � 9) 11,, ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY TLC• /ifl� [�f ❑ INDIVIDUAL ❑ COUNTYAGENCY CITU NAME STAT �1 ZIP CODE �I�1l�E yayaWlTr{ C�DEc-?3f "T 14C C . "374 lJ Jd 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION (7 RT k l (3 QoS �t c fc> a /E.L�J/�� ie.� Ove, MAILING or STREET ADDRES^�y l ✓Box to Indicate ARTNERSHIP ❑ STATE-AGENCY /� �^ /. , ` ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY •/L /'� r I �C- ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE C 9S-374 (169) 93S-SV-3J IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. Djii� Ill.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT PPLICANTS NAME(PRINTED&SIGNATURE)( n DATE >R-rka.1 OROS . F��.�� G�.Z�c-�a 11/22189 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at S1TE Ci � � z7 � -61 CURRENT LOCAL AGENCY FACT ITY ID Nom/'- APPROVED BY NAME PHONE N WITH AREA CODE D PERMIT NUMBER PERMIT PROVAL DATE PERMIT EXPIRATION DATE LOCATION DE CENSUS RA N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 2_ 7 � YES NOEl I Z CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# It / vY THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), HNLESS THIS ISA CHANGE OF SITE INFORMATIONONLY FORM A(3-2-88) 1.0ii DATA PROCESSING COPY �"'