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STATE OF CALIFORNO WATER RESOURCES CONTRAOARD FORM `A': _ \\ UNDERGROUND STORAGE TANK PROGRAM SITE a 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 VT 7 P MANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ac I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF A KESS INFORMATION N r*N) ADDRESS REST CROSS STREET I/B.lYMiwie ❑ PARTNERSHIP ❑ STATE AGENCY I IA ION LOCALAGENCY Cl FEDERAL AGENCY �fNOORVPOAL CoumY-AGFNCY M GI ME #✓w STATE ZIP ODE �TEPHO E# WITH AREACODE CA �Z[5� 7f6¢ TYPE OF BUSINESS. 2 DISTRIBUTOR ❑ 4 PROCESSOR '/Box if INDIAN EPAIDID # #of TANK'# ❑ 1 GAS STATION ❑ 3 FARM 5 OTHEfl TRUSTY LA oror ❑ /v AT THIS SITE 0 ESEEMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(AST FIR PHON It WITH AREA CODE DAYS'. NAME(AST,FIRST) PHO kyJITH AREA CODE d44A.1- �Zo9)�IGV-1r ' /A 1 NIGHTS'. NAM (AST,FIRST) PHI 471TH AREA CODE NIGHTS'. NAME(AST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) 3p NAME ,EN A�/N/'1 v1 CARE OF ADpRESS INFORMATION N///�1 MAILING or S REET A RESS ✓Sox to indicate Cl PARTNERSHIP ❑ STATEAGENCY . 1 ❑ ISORP,RATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY l'( B3''No"DUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP Cha P ONE# WITH AREA CODE , , $ p cl'�" Pit qj -75��' III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME ^ CARE OF ADQ9 S INFORMATION MAI G r STREET ADDRESS ✓Box to Maicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ KPOIDRATION [ILOCAL-AGENCY ❑ FEDERAL-AGENCY DI INVUAL ❑ COUNTY-AGENCY CITY NAME� STATE ZIP CODE� PHONE lq WITH AREA CODE (D 11 S S S//^� IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 1:1 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION IF AGENCY# FACILITY® IIDD# #of TANKS at SITE I� 0 c� 101010101 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE E DER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE IS DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINES YES NFILED NO ❑ DATE F LED ?�70 !419 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORM LY. FORMA(3-2-SS) DATA PROCESSING COPY 01