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hr'"tu��iri'•Af STATE OF CALIFORN19 WATER RESOURCES CONTRIPBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,, X94 vartr!�P C COMPLETE THIS FORM FOR EACH FACILITY/SITE 11 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N 411. I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W FACT TY/SITE NAME CARE OF ADDRESS INFORMATION ✓BoxPirdIWIe D PARTNERSHIP D STATE AGENCY ADDRESS NEAREST CROSS STREET D CORPORATION D LOCAL.AGENCY Cl FEDERALAGENCY t ClINDIVIDUAL Cl WUNTY AGENCY CITU NAMSTATE 21P ODE ITE PHONE A,WITH AREA CODE �1 q5 CA 5 0109 ZI6 6- " TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID N #of TANK's RESERVATION or F-1 w 1© . 1 AT THIS SITE I ❑ I GAS STATION ❑ 3 FARM OTHER TRUST LANDS I'v AJ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY$'. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE It WITH AREA CODE G} br0.hC"Vv\ o I&e i' 0209 —S' PHONE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE if WITH AREA CODE NIGHTS. NAME(LAST,FIRST) aoy -7 -3,a 5 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME t CARE OF ADDRESS INFORMATION �aCIL bre h�W�SUtJ ✓$ox to indicate AD PARTNERSHIP D STATE-AGENCY MAILING or STREET ADDRESS ®'CORPORRATION Cl LOCAL-AGENCY [IFEDERAL-AGENCY ❑ INDIVIDUAL [ICCOUNTY-AGENCY CITY NAME STATE ZIP�ODE-�� PHONE A.WITH AREAC DE �� L�'}O C�C,-�-U 0Cd 7/ III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ✓Box D PARTNERSHIP D STATE AGENCY MAILING or STREET ADDRESS ❑ CORPORATION N ElLOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 0.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)SOX 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# JURISDICTION# AGENCY A, FACILITY ID p p of TANKS at SITE Tiy[Z2 1610101 / CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE Chan n I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [CHECK# OCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS,AN F❑ILEO NO ❑ DAT FILO n of a3. a PERMIT AMOUNT SURCHARGEA OUNT 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. FOR A(3-2-88I • • ,� y� DATA PROCESSING COPY P