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77—" 7�m STATE OF CALIFORNI WATER RESOURCES CONTRAOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I'+ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) ~ N FACILITY/SITE ✓w r ` �� CARE OF ADDRESS INF RMATI ON I% ADDRESS NEAREST CROSS STREET ✓BmmiAwB ❑ PAATNEW ❑ STATE AGENCY �❑ WOPATgN ❑ LOCAL.AGENLY ❑ FEDERAL AGENCY .1d'MOMWAL ❑ OJUNIY-AGENCY CITY NAME n STATE ZIP CODE SITE PHONE N,WITH AREA CODE M Ci�I CQ Ls- CA — TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOq ✓BOz'INDIAN EPA ID p ❑ I GAS STATION ❑ 3 FARM ❑ RESERVATION Or ❑ �� tl of TANK'# 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME( S ,FIRST) PHONE N WITH AREA CODE IDAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE La'_b 9S°sl J- NIGHTS: NAME(LAST,FIRST) / PHONE N WITH AREA CODE NIGHTS: NAME(LAST, PHONE Al WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME ` M CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 13 LOCAL-AGENCY 11FEDERAL-AGENCY pry INDIVIDUAL ❑ COUNTY-AGENCY CITU NAMEf"_0 ca_ STATE ZIP CODE PHONE N, ogAREA �� III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) a^ NAMEnom'_/A r, CARE OF ADDRESS INFORMATION ' u - X MAILING or STREET ADDRESS ^ ✓Bon to PinROdiIOA 11❑ PARTNERSHIP ❑ STATE-AGENCY 1 \ ❑ RION ❑ LOCAL-AGENCY FEDERAL-AGENCY 1 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATF,,�r ZIPCODE PHONE Q09 WITH ARS 3-EA CODE 1S 3q3 Q-) 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. o- III. ❑t' 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 f� LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY IDB #of TANKS at SITE 3EI D I o I -a I sl I 1 1010101 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE L Avn Q S"11 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L C-OIDE CENSUS TRACT �N� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (, 1 J l.J 7-- I YES ❑ NO ❑ I I 0 0 0 �C W PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: I 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 •�� FORMA 13-2-881 � DATA PROCESSING COPY