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i STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD `yP`f`' jk FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE c� FAH\P MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ey"5'CHANGE OF INFORMATION ❑ 7 PERMANTLY D SITE fV ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cn W I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) VCO FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Gi�IJI/` �1(iFi `�T lOI-I *v,I r5 I Aelf�62 ADDRESS ` NE�jREST CROSS STREET ✓ to indicate ❑ PARTNERSHIP ❑ STATE AGENCY W�ti��oo D J LN CORPORAL ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY !� 6 S/>�I/r/ /1 � ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE �To(_�14 CA X 20 20 �l I•�(o-7 4- TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a #of TANK's 5 OTHER TRUST LANDS GAS STATION ❑ 3 FARM RESERVATION or ❑ L/�C°iC�C �-l�s� f �.� AT THIS SITE P5 ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE [40m_f 0 6l,l,I p+,l Zo 2; U r- PiR-~ C F�l �Z-I�SZ NIGHTS: NAME(LASf,FIRST) n r� PHONE /#WITH AREA CODE NIGHTS. NAME(LAST, IRSTT)) r PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Lj I l,f pKS G4aA_,, O1 V ^+sy OIL,,- . gyp. SUIS qoo f MAILING or STREET ADDRES /] I-V , !)(J Iq�� ✓ x to indicate ED PARTNERSHIP ❑ STATE-AGENCY 1-1 LOCAL-AGENCY HCl ✓w'V I ' - 6 ElINDIPDUAL ION E] COUNTY-AGENCYEl FEDERAL-AGENCY CITY NAMESTATS ZIP CODE P,H �WIAREA, COiE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) ^`�f NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I I L'I Ln� (}� ✓ ox to indicate El PARTNERSHIP E3STATE-AGENCY 19 CORPORATI D IJ` , % loo ❑ NDIIVIDUALION ❑ COUNTY-AGENCY El FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#. ITH AREA CODE C10I-4CIO P�p IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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&SIGNE) I / DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE [37-711016, 1117 CURRENT LOCAL AGENCY FACILITY IDL APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA C E CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ,9)3 , `16 -�, :?— I YES NO (` CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE -7 RECEIPT# BY: THIS FORM MUST-9ltACCOMPANIED BY AT LEAST I"'IR MORE TANK PERMIT FORM `B'APPLICATION(S), UNI FSS THIS IS A CHANGE OF SITE INFORMATION ONLY. �\j FORMA(3-2-88)� DATA PROCESSING COPY