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STATE OF CALIFORNIA WATER RESOURCES CONTROL-dOARD ""`'e FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO , COMPLETE THIS FORM FOR EACH FACILITY/SITE "'��•"-" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E97 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 50 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILTIYBITENAME LVC/� CARE OF ADDRESS INFORMATION V ADDRESS I_, NEAREST CROSS STREET ✓aNw,xiome 13PANtMMIP ❑ STATEVANLY 13 CORRAlIN El AGENCY Igg QUI 7 + circle e ElINDWIWUk ❑ <b�IINN ACEIGY ❑ FEDEIUL-AGENCY CITY NAME STATE ZIP CODE SITE PHONE A,WITH AREA CODE CA —3637 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 1 PROCESSOR ✓Box if INDIAN EPA ID If _ If of TANKY ESE ❑ 1 GAS STATION ❑ 3 FARM V5 OTHER TRUSTY ATION LANDS a ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE atf NIGHTS: NAME ST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE P AJ —3 6 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION e as Z MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME ��' CARE OF ADDRESS INFORMATION IHHIe LiS� MAILING o STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE Y.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ADM ADORBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. II. ❑ 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 COUNTY01 JURISDICTION R AGENCY R FACILITY ID S Is o1 TANKS M SITE " E-il = = 16 1016 (!) ;7, CURRENTLOCAL AGENCY FACILITY 10 0 APPROVED BY NAME PHONE 0 WITH AREA CODE 56/1 PERMIT NUMBER PERMITAPPROVALDATE PERMIT EXPIRATION DATE L ITIESUS TRACT 0 SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILE 3 D3 6 YES NO �MIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY: 'l THIS FORM MUST BE ACCOWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. W FORM A(3-2-88)