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STATE OF CALIFORNI0 WATER RESOURCES CONTROROARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ; SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , ,c COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I--► j ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 �� cm 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 6Q a �/ Co 'y 90;F &w [ ADDRESS NEAREST CROSS STREET ✓ rdoe 0 PARTNERSHIP 0 SiATEAGENA ��\\ PPORATION 0 LOX-AGENCY 0 FOM-AGENCY G U� ❑ iNgMOJA1 ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE �� vctFoy r� CA 9Sa0S 01 9v 0 s TYPE OF BUSINESS: p DISTRIBUTOR 4 P39MSSOR ✓Box if INDIAN EPA ID NRESX of TANK1 ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUSTYLANDS ION 0f ❑ N O N F AT THIS SITE 0 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE �o G/[ q -61,t y LLA.)k NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE u nJ II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION /�GL✓:�/ MAIUNG or STREET ADDRESS ✓ o indicate Cl PARTNERSHIP 0 STATE-AGENCY �J / Q I CORPORATION 11LOCAL-AGENCY 0 FEDERAL-AGENCY —7 /Cljl 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE S fv c-/c i n C r4 -5- III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION tea ✓^c1 Cv MAILING or STREET ADDRESS ✓ to indi<ale 0 PARTNERSHIP Cl STATE-AGENCY ,pp CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY (/r IS 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME `- STATE ZIP CODE PHONE N,WITH AREA CODE �f77Lk ArIn e qs-�70 - 1 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 X JURISDICTION X AGENCY X FACILITY ID X X of TANKS at SITE 3 9 O o / -7 .S 41 1 0 1 0 1 0 / CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE N WITH AREA CODE {J e-7w oZ to PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED YES NO CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: r 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. \\VILA III FORMA(3-2-88) ) DATA PROCESSING COPY '3�•