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Via" STATE OF CALIFORNIA WATER RESOURCES CONTROPBOARD yEl� JAN f i FORM `A': UNDERGROUND STORAGE TANK PROGRAM �a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° : o G I COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [_].7 P NTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITENAMEnn ,` CARE OF ADDRESS INFORMATION Kd e�,�`'AId+ ADDRESS I _ / NEAREST //J N SSTREET ✓ iW11 PARTNERSHIP ❑ STATE-AGENCY CORPORATION 11 LOGAGENC! ❑ iERA1L-AGENCYG rL ❑ INOMOOAL ❑ COUNTY-AGENCY CITY NAME /rSTATE CA ZIP CODE_ / SITE O E p,WITH AR iOE]E�O/ TYPE OF BUSINESS: ❑ 2/\DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a J( 5 4✓� RESERVATION or If of TANK# ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE S eh Za C 66— 6/ NIGHTS: NAME(LASf,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME Oe �- SCARE OF ADDRESS INFORMATION l alp a /es Lfq MAILING or STREET AO 13S! _ -/Box to indicate 13 PARTNERSHIP ❑ STATE-AGENCY G/ SS ' 15 .0 El CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY �j ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME S—�c�✓ STATE ZIP CODE ` PHONE If,I HAREA CODE !'�A (1/FT/-y III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) 5 NAME -T ` f� ^�v� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS / (� J` ✓Box to indicate 13 PARTNERSHIP 13STATE-AGENCYp! 0 D D� "QDO El 11 INDIVIDUAL 11 11 LOCAL-AGENCY 11 COUNTY AGENCY 11 FEDERAL-AGENCY CITY NAME � STATE 21P CODE PHO W�AREA COD S J y66 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY 10# If of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE Gwm A 53 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DIS COO BUSINESS PLAN FILED DATE FILED C 01 0 YES NO /— ZO-O l CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT F O R M 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88), DATA PROCESSING COPY