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STATE OF CALIFORNIA WATER RESOURCES CONTROAARD FORM AA': a '�' UNDERGROUND STORAGE TANK PROGRAM SITE V FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ ❑ ❑ / PERMANENTLY CLOSED SITE 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE (;OMPLETED) FACILITY/SITE NAME, CARE OF ADDRESS INFORMATION ADDRESS �l)1.�J L _ ) ��' NEAREST CROSS STREET ✓g WN Cl PAR NEA911P ❑ STATE 43 y7/y C ❑ C01"I41TON ❑ LOCAL AGENCY ❑ FEDERAL AGENCY CITY NAME ❑ INDMDUAL ❑ COUNTYAGENC/ SSTATE ZIP CODE f0c SITE PHONE M,WITH AREA CODE TYPE OF BUSINESS: CA �`��' -I/ Y77 7 -1/_54 j ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID M ❑ 1 GAS STATION 23 FARM ❑5 OTHER RESERVAUST TION of ❑ M of TANK'S AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) GAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) -�C it /' 1 .q5'1? PHONE^p WITH AREA CODE NIG TS: NAME(LAS FIRST)L / -S/ Y- air PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) S PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) ENAMECARE OF ADDRESS INFORMATION Boz to intlicale ❑ PARTNERSHIPCORPORATION ❑ LOCALSTATE-AGENCY❑ INDIVIDUAL ❑ COUNTY GENCY ❑ FEDERAL-AGENCY AGENCY STATE ZIP CODE PHONE p,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME _ CARE OF ADDRESS INFORMATION Sj//I MAILING or STREET ADDRESS ✓Box to intlicate ❑ PAgTNERSHIP O CORPORATION ElLOCAL-AGENCY El CI STATE-AGENCY ❑ INDIVIDUAL 11 COUNTY-AGEFEDERAL-AGENCY CIN NAMENCY STATE ZIP CODE PHONE II,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: I. Ell� if. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY M FACILITY ID M M of TANKS of SITE 0 a ( 5 8 Cl= CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE M WITH AREA CODE 17 mrv5,L 4 _&P /7-VA PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION�O(xE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PIE D =J1 LI a i c) r� YE [:] NO CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE ECEIPT•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 ON . �/ FORM A(3-2-68) .