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STATE OF CALIFORNrK WATER RESOURCES CONTRdrBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o C COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ I PERMANENTLY CLOSED SITE F'-a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 99 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) � CS FACILUY/SITE NAME CARE OF ADDRESS INFORMATION (� /"7a -1Yla..l �av,E Qr. ADDRESS (, NEAREST CROSS STREET ✓Ik.bmiele D PAMNERGBIP D YDi FE)ffiAGAoMIALo � CD EGNECNY r, ONfANNC CITY NAME STATE 21P CODE SITE PHONE II,WITH AREA CODE un CA 3 - TYPE USINESS. ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a 1 If of TANK's GASSTATION E] 3 FARM El OTHEfl TRUSTYLANDS ATION o El /",F/ 67/U� AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE u �ti �< s - 1) !� �! Cavy s a/-8 97 JaHITTS NAME(LAST,FIRST) �F - Wlr: -c�CODE NIGHTS'. 1N�AME ST,FIR ) PHONE N WITH AREA CODE G•/e of c O4� - b oLve- op lef c lC S e''e a (ao�-e 93/t7 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION O /Tn /720or-e MAILING or STREET ADDRESS _ ✓Box to indicate D PARTNERSHIP D STATE-AGENCY /� D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY 3030 Al r[ Qi R' S7-j5_ 9/,;tD INDIVIDUAL D COUNTYAGENCY CITY NAME STATE21P CODE PHONE N,WITH AREA CODE Sa sa tfa C4 �/ YY(o�e— III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATEAGENCY . ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE 21P CODE PHONE N.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: I. IL ❑ Ill. ❑ 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 R JURISDICTION R AGENCY# FACILITY ID# R of TANKS at SITE EE = = 10101 / y ,2 lel 10 1010 / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE G1 SR 7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 01 YES NO ❑ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: `I1 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. I FORM A(3-2-813) J( `\`Vc/ w1 DATA PROCESSING COPY �B�