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9rj,JoF r STATE OF CALIFORNIO WATER RESOURCES CONTRIAIOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM . . .; . . SITE FACILITY/SITE, INFORMATION and/or P RMIT APPLICATION �R41�o `p� COMPLETE THIS FORM FOR EACH CILITY/SITE 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION TLY CLOSED SITE MARK ONLY E] C' ONE ITEM El 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE L FACILITY/SITE INFORMATION S ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NCARE OF ADDRESS INFORMATION -' - 9 ADDRESS NEAREST GROSS STREET rdcate Cg ❑ RARTNERSHiP ❑ STA E-AGEIJ(l _ RppRATIGN. '0LOCAL-AGENCY ❑ FEDERAL-AGENCY f1 R/I INDIYIGUAL ❑ COUNTY-AGENCY STATE ZIP CODE SITE PH0 11,WITH A�R}EA COD�r1 �j CITY NAME CA �1, �� 9 iTr V 0 CJ TYPE OF BUSINESS: F—] 2 DISTRIBUTOR d P E550R Brox ill INDIAN EPA ID N A of TANK's To 1 GAS STATION 3 FARM OTHER TRUST LANDS ATION or Q AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE p WIT�Afl CODE- DAYS. j}E DAYS: NAMEj(L�A/ST,FIRST) � tj, �^' A AKMJ1�R Z6 - Y � 1 ,VTPHONE N WITH AREA CODE NIGHTS', NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NA E[LAST,FIRST) II. PROPERTY OWNER INFORMATION S ADDRESS - (MUST BE COMPLETED) NAME - CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS o indicate ❑ PARTNERSHIP ❑ FEDERSTATEAL-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL_ ❑ COUNTY-AGENCY STATE ZIP CODE PHONE 9,WITH AREA CODE CITY NAME Nh TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) t G RE OF ADDRESS INFORMATION NAME 7 /� 61 ..lG� /eer the MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY C_O*3R'PORATION [3��LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL COUNTY-AGENCY UPHDNWIH AEACD `STATE ZIP CODE ` CITY NAME ?� !>7fl IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE{i)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ ll. 111. 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 p5i JURISDICTION fl AGENCY M FACILITY ID N #of TANKS at SITE EEI LLLI LJ-iJ r� l - 6 3 AGE ACIL ID N APPROVED BY NAME PHONE N WITH AREA CODE __T r {�Y.' PERMIT APPROVAL DATEPERMIT EXPIRATION DATE OENSUBTRACTN SUPERVISOR-D18TRICT CODE BU81NE88YP SN�ED NO DATILEFEE CODERECEIPTNPERMIT AMOUNT SURCHARGE AMOUNT 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(3-2-58)t _-