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STATE OF CALIFORNik WATER RESOURCES CONTRO BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -m ; n° z IQ X COMPLETE THIS FORM FOR EACH FACILITY/SITE `^<�.oaH,>> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F& ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 0) I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) C FACILITY/SITE NAME CARE OF ADDRESS INFORMATION DE : -`ru�lviv, G, ADDRESS NEAREST CROSS STREET ✓ WII Cl PARTNERSHIP 0 STATE AGENCY a /. '` MRATION 0 LOCAL AGENCY 0 FEDERAL AGENCY K ❑ INDIVIDUAL ❑ COLIW AGENCY CITY NAME STATE ZIP CODE S TE PHON k,WITH AREA CODE i CA 5366 ao TYPE OF BUSINESS: 2 DIST UTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # RESE ❑ T GAS STATIONEL�R<RM ❑ 5 OTHER TRUSTYLANDS o ❑ / Vl/vl.�� Mol TANK'a O AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE ao9 54q_W4?7 NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME J S CARE OF ADDRESS INFORMATION �Q GLO ,S' /� 7 � MAILING or STREET ADDRESS ✓Box toinoicale Cl PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME N CARE OF ADDRESS INFORMATION SaeyL.2 ce S S / f2.. MAILING or STREET ADDRESS ✓Box toiaoicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE A.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: L ❑ I. ❑ 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 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY M FACILITY ID M M of TANKS at SITE [m] a © 1 L o 000a CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WIT"AREA CODE D 9,4 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED a3• '3015, YES ❑ NO ❑ q /a s' CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONILYr� FORM A(3-2-8B) - \J �; n� Awpr DATA PROCESSING COPY VMOL