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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM IA': = A UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT En-,-CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE P ONE ITEM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / C G I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME ^ S ^ I V CARE OF ADDRESS INFORMATION ADDRESS ^ ^ NEAREST CROSS STREET ✓Np,b YdNale Ill RMTNERSW D STATE AGENGf (� oIr /�^ �/ ElCORPOMION 11LOCKAGENCY ❑ FEDERILAGEND rte\ ' -\ I �! S 1 ❑ INOVIWAL ❑ COJNtt AGENCY CITY NAMEr—1 STATE x ZIP CODE C' SITE PHONE N.WITH AREA CUE TYPE OF BUSINESS: F—] 2 DISTRIBUTOR 4 PROCESSOR) ✓/Rox(it_IN�DIIAN EPA ID N 9 S J RESERVATION or Not TANK'# \ ❑ I GAS STATION ❑ 3FARM SOTHER TRUSTLANDS ❑ AT THIS SITE 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 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION /'I Vi�� I 'l A- MAILING or STREET ADDRESS ✓Box Lo meicale PARTNERSHIP D STATE-AGENCY ORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY INDIVIDUAL D COUNTY-AGENCY CITY NAMEL STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NA E CARE OF ADDRESS INFORMATION GkU` fF F A- e7A(-- MAILINGorSTREET 1 ADDRESS' /(/c� ✓Box to indicate PARTNERSHIP D STATE-AGENCY G-L 2Z `'- /max `�T /J� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY /�F. ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. El 111.❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE Do 1 /1 / 1710 1 10 (� o CURRENT LOCAL AGENCY/^/FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE V Or� ..;� T:P- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATTIION ODE CENSUSTRACTO ^ SUPERVIS717RICT CODE BUSINESS YP SN FILED HO ❑ DATE FILED CHECK# PERMIT AMOUNT/V SURCHARGE AMOUNT FEE CODE RECEIPT BY:�v THIS FORM MUST BE ACCOMPANIED BY WST(1)OR MORE TANK PERMIT FORM 'B'APPLICATI , UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. r♦ FORM A(3-2-88) DATA PROCESSING COPY