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STATE OF CALIFORNIA WATER RESOURCES CONTROMOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE INFORMATION and/or PERMIT APPLICATION '° COMPLETE THIS FORM FOR EACH FACILITY/SITE ��•"'" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ET=GE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT •❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION 8 ADDRESS— (MUST BE COMPLETED) Ffl LO SITE NAME CARE OF ADDRESS INFORMATION JA6 G GQ ADDRESS �l� NEARES,T.CROSS STREET ✓eww+ ❑ PARTNESSw ❑ STATE KOO �(JF/ �/`YI 11 IN WCUAL ❑ WI TY AWIO ❑ fE00W Mf/1LY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA s23� TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 1 PROUSSOR ✓Box A INDIAN EPA ID N ❑ El a 1� /of TANK'N ❑ 1 GASSTATION 3 FARM 5 OTHER TRUST LANDS ❑ 4�+TLS Oco S 73 6l 6 AT THIS BITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE Af 1Cj ' 14,9660le �Z�� 333-223 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 4,0o65 40-6 Zoq) 36S-s' II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION G GoYeP. MAILING or STREET ADDRESS �.�--' ✓Box W micele ❑ PARTNERSHIP 13STATE-AGENCY '70Z:> 5 "�F � G / Cl O NDIPORATION ❑ COO ALAGENCY UNTY-AGENCY 11 FEDERAL-AGENCY clTv NAM G�K.1 STATE� zip CODE y0� PHONE �fiDE �J 636 N.WITH AREA cD6o r III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFOHMATION MAILING a STREET ADDRESS ✓Box to ind"le ElPARTNERSHIP ❑ STATE-AGENCY /I OV S�T+E�7� El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE I.WI H AREA CODE A..,--f— S?�o �636-6vGJ IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOV!ADI MIii SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY11 JURISDICTION Y AGENCY Y FACILITY ID Y Y of TANKS SI SITE 2jGl (' 1 O ! 3 oao CLN1REl1T LOCAL AGENCY FACILITY IO F APPROVED BY NAME PHONE Y WITH AREA CODE G P $� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [LOLCATIONCODECENSUS TRACT 1 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OA D YES NO 7i/' Gll PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 1 BY: T \ THIS FORM MUST BE ACCOMPANIED BY AT LEA'' OR MORE TANK PERMIT FORM W APPLICATION(S), 'SS THIS IS A CHANGE OF SITE INFORMATION ONLY. V 'FORM A(3-2-M)