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STATE OF CALIFORN'Ad WATER RESOURCES CONTRTi BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' o COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E95 CHANGE OF INFORMATION 7 P LY CLOSED SITE N ONE ITEM ED INTERIM PERMIT ❑# AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION MS V ADDRESS /� G✓ NEAREST CROSS STREET ✓30 i,inoa ❑ PNNERMIP IATfC Elhl90 o 12CDPOM7 ❑ LOMAGE10 ❑ FEDBMLAGEN5T//' 4-71 ❑ Ni ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE CA 6 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ FOCESSOR ✓Box if INDIAN EPA ID # ❑ 1 GAS STATION ❑ 3FARM V5 POTHER TRUSTLANDSATION UI ❑ AT THIS SITE AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) / PHONE#WITH AREA CODE DAYS- NAME(LAST,FIRST) PHONE N WITH AREA CODE 7�5N N l i/lI Mcg' /1?f1/2 Ait Jr.-... _�Z NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CO E NIGHTS: NAME LAST,FIR9T) PHONE#WITH AREA CODE 5 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME �Jq— ��w / �� ARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓BOX to indicate ❑ PARTNERSHIP STATE-AGENCY �D Q /'"� J l ElINDIVIDUALDIVIDUAL PORATION 13 COUNTY AGENCY 11FEDERAL-AGENCY ✓ CITY NAME � _ / STATE - ZIP CODE� / PHONE p,WITH AREA CODE III. TANK OWNER INFORMATIONN& ADDRESS— (MUST BE COMPLETED) NAME (� � M I" `L ASL CARE OF ADDRESS INFORMATION,57' MAILING.1 STREET ADD SS D /✓Box to linnddiicate G❑ PARTNERSHIP ❑ STATE-AGENCY AMppp (L/ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY / %O / 7 ❑ INDIVIDUAL Cl COUNTY-AGENCY CIN NAME " � STAT ZIP CODE _ PH #,WITH ARE E C le'6-m IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ it. ❑ III. Flliii THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED e.SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY# FACILITY ID N M of TANKS at SITE [ 10101 E2�I o00 CURRENT LOCAL AGENCY FACILITY to X,p'A APPROVED BY NAME PHONE N WITH AREA CODE [ '--V67 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CIENSA TRACT SUPERVISO DISTRICT CODE BUSINESS PLAN FILED DATE FILED 4' 9 3 ZU YES E] NO ❑ HECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:/"' �OF THIS FORM MUST BE ACCOMPANIED BaaaaaaaaaaY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-SB) S �� DATA PROCESSING COPY \1