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STATE OF CALIFORIO WATER RESOURCES CONTRIBOARD eP FORM `A': SUNDERGROUND STORAGE TANK PROGRAM �V * , �o z � n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m 10 17 COMPLETE THIS FORM FOR EACH FACILITY/SITE oaH.H MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT �CHANGE OF INFORMATION ❑ 7 PER D SITE I-J ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1 N I. FACILITY/SITE INFORMATION & ADDRESS—,(IMUST BE COMPLETED) 1 Ql FAC4Li1b GIT NAME 01 S1 V(.^'hn vn I rLt CDV (A t'� A ��11 CA OF ADORES INFORMATION (no �bn ;s s ADDRESS rr NEAREST CROSS STREET ✓Bw to M.16 ❑ PARTNERSHIP ❑ STATE AGENCY G S OYl OV 0. .StY-1 e- ❑ CORPORATION B-TOCAL-AGENCY ❑ FEDRUL AGENcr Cl INDIVIDUAL ❑ COUNTY AGEN9 Clry NAME +-0 STATE ZIP CODE SITE PHONE ^AREA CODE CA t� TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID q ❑ I GASSTATION ❑3 FARM �3'O PROCESSOR RESERVATION or #of TANK's /, I TRUST LANDS ❑ AT THIS SITE V EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE �— NIGHTS: NAME LAST,FIRST) PHONE p WITH AREA CODE NIGHTS. Nafit&(64BTY+RST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMECly I �C�� CARE OF C INFORIA TION MAILINGor^STR6j6TADDRESS F•l—IJ-J,,(',' ✓Box to indicate 'll❑ PARTNERSHIP ❑ STATE-AGENCY ON� �dv �' em3l ❑ NDIVIDUALION COUNTY-AGENCY ❑ FEDERAL-AGENCY CIN NAME STATE ZIP CODE PHONE p,WITH AREA CODE Sock�O� .0 gS�_oa- qk4a� III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) N1TIl.�11 �� •� �� D CARE OF ESSINFORMATION o lean I<- MAILING or STREET ADDRESS ✓Box tointlicale ❑� EIRiTNERSHIP ❑ STATE-AGENCY 2 I �OY Y►13 El CORPORATION Qe[OCAL-AGENCY 11FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME GTAjfi ZIP CODE�� PHONE AREA q. CODE �ockt�r. q5 d^, 9 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. © Ill. ❑ 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 N FACILITY ID It #of TANKS at SITE m � a0 o � d CURRENT LOCAL AGE-CY FACILITY ID k, �O IVED.BY NAME PHONE a WITH AREA CODE PERMITNUMBER . . 1AVlG AIV( PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESSP 3 N❑FILED NO ❑ DATE I FILE _q C� t l7J\ CHECK# 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. \t\/ FORMA(3-2-88) VVV 0 DATA PROCESSING COPY 0