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STATE OF CALIFOR" WATER RESOURCES CONTAdL BOARD o, i FORMA': UNDERGROUND STORAGE TANK PROGRAM a� 0 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONm � C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ONE ITEM 1-1 2 INTERIM PERMIT I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACIUTY/SITE NAME CARE OF ADDRESS INFORMATION ORD 1 0 1n/( Co . ADDRESS NEAREST CROSS STREET ✓Amb Mrye ❑ PAHTNEASNIP El STATE AGDO ($5 . f' GIiF Ga<J °❑ INDmom ❑O LOCALAGm ° 1mERu Ar>ENLY CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE STOI�I�I CA .75:? 7 Zo Zo9) �bS TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID Al If of TANICp Z ESE ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYATION LANDS of ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE If WITH AREA ODE DAYS: NAME(LAST.FIRST) PHONE Al WITH AREA ODE rn/E � (zq) 4(65 - NIGHTS: NAME(LAST,FIR T) PHONE p WITH AREA CODE NIGHTS: NAME fl-AST.FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION _� MAILING v�SSTREET ADDRESS ��..11.� •� ,�f1 /� ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY EI�Oy6 UGv�xA' I 11 INDIVIDUAL El LOCAL-AGENCY ° FEDERAL-AGENCY Cl COUNTY-AGENCY NCY CITY NAME STATE�/ ZIP CODE PHONE p.WITH AREA CODE ZDLj Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAI}III G STREET ADDRESS I/Box to indicate El PARTNERSHIP CISTATE-AGENCY y N_ AQ p w El NDIIVIDUALCORPORATION D LOCAL-AGENCY❑ COUNTY-AGENCY ° FEDERAL-AGENCY CITY NAME STATE ZIP jCODE -�w PHONE M,WITH AREA CODE y IV. LEGAL NOTIFICATION AND BILLING ADDRESS -_ CHECK ONE(1)Bol!INDICATING WHICH ABOVE AMISS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 1. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TR CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION# AGENCY k FACILITY ID R R of TANKS It SITE " 3 IC2 d / Z 7 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE p WITH AREA CODE G01-6L 0' PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS!TRACT p SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE 4/ 23 . 32 YES E] NO ❑ 6 CHECKp PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT0 BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONIS),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) \ �� J t Ir)