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.4. �v"Cr'TL`*�'.�+►s -nw m�... -.....->-s�r�ivRl+r+v STATE OF CALIFORNI WATER RESOURCES CONTROOARD wP: •.sa FORM `A': UNDERGROUND STORAGE TANK PROGRAMW ,gym _ zo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Y COMPLETE THIS FORM FOR EACH FACILITY/SITE Ca�IFORNxP MARK ONLY 2Sf NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ' I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 0 FACILITY/SITE NAME CARf OF ADDRESS INFORMATION I, u.' r rAfJ G e o 5 ti w . Lnw Sr ADDRESS NEAREST CROSS STREET ✓Box to indicate ElPARTNERSHIP ElSTATE-AGENCY i r ❑ CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY f � 1 � Ln 7/G B'TNDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA DE �j CA 95 3 -3X03 TYPE of BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's ix RESERVATION or � 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ &W L, AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) L PH NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Lt� Z�9 3 -"y 14 NIGHTS: NAME(LAS-0,FI ST) /' P ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE fkQ�T (L.-l..l 6vw /l II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Ill)I 4_ Wit' pep e� MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 452- w �lu�� El CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY W NDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STA ZIP CODE PHONE# WITH AREA CODE (?5 S 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 5 — WE, MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ElSTATE-AGENCY El CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY Lu , UJ€L-L- NDI IDUAL Cl COUNTY-AGENCY CITY NAME STAYE ZIP CODE VHONE NWITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR 130TH LEGAL NOTIFICATION AND BILLING: I. ❑ if. Iil.❑ 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 F JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE © 1 0 -14- 0 a 00 O 3 AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT# SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED�3,a O YES ❑ NO ❑ ZZ��PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 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. FORM A(3-2-88) 1, OF DATA PROCESSING COPY wJf