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. OF CALIFORN�In —�Wpq RESOURCES CONT�L BOARD s ��: "'m a UNDERGROUND STORAGE TANK PROGRAM E , FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE Ir ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 'I I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) C7Cl� FACILITY/SIT{NAME CARE OF ADDRESS INFORp,TION C url l�( nc- 91v�1 L;ra6 Pri r k� ADDRESS /� �o `f^ NEAREST CROSS STREET ��✓B�tl ❑ PARINBEHIP ❑ STATE AGENCY 5 V `rJ l l� A OM ON ❑ LOCAL AGENCY ❑ FEDERAL.AGENCYn ❑ Ixomouu ❑ couxnaGExcY CITY NAME S+oc� V STATE C E SITEPHON .,WITHAREACODE a\l '^ CA �t2 0j 20 9t y�- 3 z�1 TYPE OF INESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID . 1 GASSTATION ❑3 FARM ❑5 OTHER TRUSTESERYLANDS ATION OT ❑ V AT THIS SITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAp�,(LAST,FIRST) PHONE.WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE.WITH AREA CODE lieWc— R A . (�c u� o n LITS %3� I(v NIGHTS: NAME(LAST,FIRST) PHONE.WITH AREA CODE NIGHTSNAME(IAST, ST) PHONE.WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION IU0,nd&r A 5o arL MAILING Or STBEET�DSS ✓Box to indicate 11 PARTNERSHIP ❑ STATE-AGENCY Vim/SO) s� �"'� 11 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAM STA ZIP CODE ` PHONE.,WITH AREA CODE an ' . If 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME I ��C O CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS II/�1 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY a( kt-4 - ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY v� ❑ INDIVIDUAL ❑ COUNTY-AGENCV CITY NAME STAJ�� ZIP 4DE PHONE.,WITH AREA CODE ��n L( S �� I `F (OS IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. it. ❑ 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 k JURISDICTION 8 AGENCY. FACILITY ID R N of TANKS at SITE C) I l I -� � I CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE V OA PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATF ODE CENSUS TRACT M SUPERVISOR-D STRIQCT CODE BUSINESS PLAN FILED �/ 3 .� ( b YES NO I CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT. BY: 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(3-2-88j • • DATA PROCESSING COPY I