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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMA : UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 16, I COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAM CARE OF ADDRESS INFORMATION 2- l VAW A fuet5 ADDRESS 3J� NEAREST CROSS STREET PARTNERSHIP O RG�ARAMN ❑ FEDERAL> � ❑ fAUN -AGNCY 4A+ CITY NAMES7o /. STATCA ZIP SIT PHON�W AR CODE C,A� TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR CESSOR ✓Box if INDIAN EPA ID # J`��`'1 940ITANNKK'F SEATION I GASSTATION ❑ 3FARM 5OTHER RUSTLANDS or F-] ❑ 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 If WITH AREA CODE iw,�t7M,e fflb -l6 - 66-59 NIGHTS: NAME(LAST,FIRST) PHONE B WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE (! I L -4161- fW/p 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPL TED) NAME CARE OF ADDRESS INFORMATION li LI b rru MAILING or STREET ADDRESS O , / xto uoic.I. D PARTNERSHIP D STATE-AGENCY BY CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME /l /' CARE OF ADDRESS INFORMATION MAILING or STRFFFF��ADDRESS Q✓�Y/JC xto inc icate D PARTNERSHIP ❑ STATE-AGENCY (I� 6 Za CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY r INDIVIDUAL D COUNTY-AGENCY CITY NAME S7/<-A/ ST C-,4 ZIPgpDV 2d / PHONE p,Oo?-WIH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS `/�IJ�'- S OtO/ I CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. III.❑ I 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 COUNTYIN JURISDICTION K AGENCY M FACILITY ID R k of TANKS at SITE ff 0 1 k 14P 10GU CURRENT LOCAL AGENCY FACILITY ID M APPROVED PHONE If WITH AREA CODE S a 31 PERMIT NUMBER PERMIT APPROVAL DATE / �f PERMIT EXPIRATION DATE 2) LOCATION CODE CENSUS TRACTk SUPERVISOR-DIB RICT CODE BUSINESS PLAN FILED DATE FILED ' 2 Q YES NO CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X 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 ONLY. `\ FORM A(3-2-88) DATA PROCESSING COPY - .W(