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ORM 'A': &ARD SITE UNDERGROUND STORAGE TANK PROGRAM • _I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / COMPLETE THIS FORM FOR EACH FACIUTY/SITE MARK ONLY ❑ 1 NEw PE ONE ITEM ® ❑7 RENEWA RMR ❑y CHANGE a.KOIIMAT10N ❑2 INTEPoM PERMIT ❑ A AMENDED PERMIT ❑T PE LY ❑6 TEMPORMry SDE CLOSURE 1. FACILITY/SITE INFORMATION 6 AD /SITE NAMFr DRESS — (MUST BE COMPLETED) F � ✓ 1 C 1 �E OF AODIESS INFOIMMTKM ADDRESS Y IJE<VIEST CROSS STREET CITY NAME "v (VD WPWTOI ❑ IOUf� ❑ S1AfPALAGLY +cLLa A ANAGEN.Y STATE 'ave'[ 0 CDINDAW �CBILY CA PHONE I.MTN AREA CODE 02JOF BUSINESS. ❑T � ❑, ✓ /�' BRVATIONor EPA 10 1 AN 1 GAS STAigN ❑ 7 RARU ❑S OTHER TTRRUUSI LLANi DS a ❑ I3 E o(TANK"T EMERGENCYCONTACT PERSON(PRIMARY) AT THIS SITE D NAME ILAST FIRST) EMERGENCY CONTACT PERSON(SECONDARY) s PHONE•MTN AREA CODE DA t NAME BAST. "IS,) NlGkffWITH PHONE 1 WITH AREA CODE nFtS S S NAME(LAST.FIRST) PHONE I TH AREA CODE NAME BAST. 1 PHONE I MIN AREA CODE II. PROPERTY OWNER INFORMATION 3 ADDRESS — (MUST BE COMPLETED) R I ADDRESS(AplX TION w STREET AGGRESS �Bo' PARTNERSHIP Cl AME O INDNMALT'� COUNTY-AGENCY LCAGENCY ❑ FEDERAL-AGENCY I ,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) Zy .Z> ADDRESS NKORMAT*N N STREET ADDRESS O �COREORATKkI a PARTNERSHu, 0 STATE-AGENCY Cm NAME ❑ [RON10UA1 D LOCH-AGENC/ O ML-AGENCY ® COUNTY-AGENCY Z� STAT 21P WITH AREA CODE IV. EGAL NOTIFICATION AND BILLING ADDRESS ECK ONE(1)BOK INDICATING WNN:N ABOVE ADDgEBy SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AR0 BKLNQ L ❑ K ❑ 4 THIS FORM HAS BEEN COMPLETED UNDER PENAL N OF PERJURY,AND TO THE BEST OFBPY KNOWLE IIL❑ APPLIGN TS NAME(PRINTED A SIGNATURE( OGE IS TRUE AND CORRECT DATE LOCAL AGENCY USE ONLY OUNTY I JURISDICTION I AGENCY, FACILITY 1D• o1 TANK8MSITE LOCAL AG[NCY FACILRT 10 / AJ 4OVEO BY XAYE O / M10N[IWITNMGCOO! MR NUMBER APPIIGYAL DAT[ i�. ? i Cr L I j KRMD E[PI TNIM T[ CODE N S TRACT[ �/ 38 Y'MOR-0IETRICi CDD( .OfIN[tE BANNED PLAID CM[CRI RMTT AYp(NT O[CNMGE AMOUNT FEECOYES ORtC[IR IO ❑ �I —,�I;� .J J ; ! by: THIS FORM MUST SE ACCOMPANIED SY AT_LEAST(i)OR MORE TANK PERMIT FORM 'B'APPL1CAT"Sl UNESS THIS IS A CHANGE OF SITE INFORMATION ONLY.