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STATE OF CALIFORNIA- WATER RESOURCES CONTROL wOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SITE 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 ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cl 7 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION s. os-to S�rYir ce vin taNc� Acle F A,/,AOA) ADDRESS NEARES [CROSS STREET •xx/�� ❑✓Bm COffORkTION D PARTN�YII' ❑ %TEhj: 7j AJT'� (dyNv�tS laN�-' 0 NONDUN 0 CO1NiY AGENCY P� CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE r CA ,�r3 -?996 20 -7W-10Z TYPE OF BUSINESS'. ❑ @ DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N ❑ I GAS STATION [:] 3 FARM 75 OTHER RESERVATIONRUST LAND$or ❑ X of TANK'a AT THIS SITE Y 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 saA/ O —5'62- 6 r NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE n/ " 9c43— II. PROPERTY OWN R INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME I CARE OF ADDRESS INFORMATION PS fii SP //G2 MAILNNG or STREET ADDRESS ✓Be.to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAMESTATE ZIP CODE PHONE N.WITH AREA CODE IF k-bAJ C 1 '75,2/3 J 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION SC.mr GS MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D STATE AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ASOYE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. it. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION S AGENCY k FACILITY ID N S of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE S J PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXPIRATION DATE E DE C��EAANSUS TIUCTN SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILED ,? 0 3 � YES ❑ NO ❑ .2_ 90 RERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS TNIS IS A CHANGE OF SITE INFORMATION ONLY. l\/) FORM A(3-2-88) / A,jO '"