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STATE OF CALIFORNIb.. WATER RESOURCES CONTRO6,oOARD FORM `A': _gym UNDERGROUND STORAGE TANK PROGRAM SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION °o p �i COMPLETE THIS FORM FOR EACH FA ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7�ERM&MLV CLOSEDLl ❑ / ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION 0-r14F I ITY/SITE NAME S w ADDRESS AREST CR STREET ✓SoM to ilbeaK ❑ PARTNERSHIP ❑ STATE 5) S� n C - ` ry1 O� (T^ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDEA L-AGEN w t E/'{bL'J FI+W K�� ❑ INDIVIDUAL ❑ COUNtYAGENCY �D CITY NA STATE ZIP CODE SITE PPHN EC.WITH AREA CODE CA N V TYPE OF BUSINESS'. EPI # / 2 DISTRIBlJTOR ❑ 4 PROCESSOR Box iF INDIAN �AFD /� #of TANK'eRESERVATION or ❑ 00 d0193y6SAT THIS SITE I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS v IEMERGENCY CONTACT PERSON(PRIMARY) MERGENCY CONTACT PERSON(SECONDARY) DA NAME(LAST,FIRST PHONE'WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE p WITH AREA CODE u�')d 935 _)99 b NIG NAME(LASE FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE .j ao� II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ` ,�� CARE OF ADDRESS INFORMATION VV PS hj� MAILING or STREET ACORESS ✓Box to indicate 13 PARTNERSHIP [ISTATE-AGENCY O I j_y W� ` CORPORATION 1:1 LOCAL-AGENCY ElFEDERAL-AGENCY (i F C NDIVIOUAL ❑ COUNTY-AGENCY CITY NAME STA/`t x/155 T 71 ODE PHONEA.WITH�ARiA GOOE n -VC'/3 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME ++ 11 CARE OF ADDRESS INFORMATION VN/ MAILING or STREET ADDRGEEE��$S ✓Box to Indicate 11 PARTNERSHIP [I STATE AGENCY 33 (, x El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY �41u— P40 V o \ Y ❑ INDIVIDUAL Cl COUNTYAGENCY CITY NAME /�� ' S1 E ZI CODE PHONE N.=ITR AREA CODE �1 �i53� au �s- IV. LEGAL NOTIFI ATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ If. III. ❑ THIS FORM HAS BEEN COMPLETED YNDER PENALTY OF PEIRqRY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. AUL ANT'S NAME(PRINT D& LOCAL AGEN Y USE ONLY u COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE U 1 31E 101010t CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 14 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIOj!C�DE CENSUS TR T N O SUPERVISOR-OISTR CODE BUSINESS PLAN F❑ILEO NO ❑ DATE FILED re of CHECK(# PERMIT AMOUNT SURCHARGE AZ MOUNT FEE CODE RECEIPT# BYlrf,�� 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./ FORMA(3-2-88) J( 1/ DATA PROCESSING COPY