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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 'o P COMPLETE THIS FORM FOR EACH FACILITY/SITE 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANOTLY CLOSED SITE MARK ONLY F7 cl 9 ONE ITEM El INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ..��.� Y.A1 Icr eF rAUPI FTFD► °ACILITY/SITE INrVIIIBIAI lvn m nvvnwv 1.-.-- -- ------ - SGn�e Cc -s Q.b a Inc— NAME CARE OF ADDRESS INFORMATION ✓ 80x to indicate O PARTNERSHIP ❑ STATE -AGENCY Y/SITE NAME 1<IAL 1)6)ti P2ov6Kjr- /ss O INDIVIDUAL ❑ COUNTY -AGENCY NEAREST CROSS STREET ✓BRbMTD ❑ lSlAPOfIAixJll ❑ PAARIEAGO O FOMLSTATE ENL' ❑ LBGl-NGENCY ❑ iR1ER14AffALY FADDRESS �L o 0 0] N .AA Y �( a / 5 /V. STATE ZIP WDESITE PHONE N. WITH AREA CODE AME CA SURCHARGE AMOUNT F BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓ Box if INDIAN EPA ID x of TANK'# / RESERVATION or OTHER ❑ /_/7 o df TNIS SITE I GAS STATION ❑ 3 FARM 5 TRUST LANDS 5,24o I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE N WITH AREA COOE DAYS'. NAME (LAST, FIRST) PHONE N WITH AREA CODE rR0E7 QN, fIL3�eT ao9) Nl?- 5,'89 NIGHTS: NAME (LAST. FIRST) PHONE N WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE N WITH AREA CODE Tg )-IN a09) Y6 I/- 442a 11. PR �.w... .mmncee lull ICT aF CITYVI FTFu1 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION SGn�e Cc -s Q.b a Inc— NAME MAILING or STREET ADDRESS ✓ 80x to indicate O PARTNERSHIP ❑ STATE -AGENCY CARE OF ADDRESS INFORMATION 1<IAL 1)6)ti P2ov6Kjr- /ss O INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME MAILING or STREET ADDRESS ZIP CODE PHONE N. WITH AREA CODE LOCATION CODE ✓ Box to indicale ❑ PARTNERSHIP ❑ STATE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY �( a / 5 /V. _ bF_ VES JR.I� DATE FILED O INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME SURCHARGE AMOUNT STATE ZIP CODE PHONE p, WITH AREA CODE l`vD i /_/7 o df 5,24o I III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION SGn�e Cc -s Q.b a Inc— FACILITY ID N S o1 TANKS BI SITE D 1 o 1 -2 I :0= C) I U/ MAILING or STREET ADDRESS ✓ 80x to indicate O PARTNERSHIP ❑ STATE -AGENCY APPROVED BY NAME PHONE N WITH AREA CODE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY O INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE N. WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS -CHECK ONE (1) BOK INDICATING WHICH ABOVE ADMEU SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ 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 I nrAl AGFMrV I IRF nMl v COUNTY K q I JURISDICTION R AGENCY N FACILITY ID N S o1 TANKS BI SITE D 1 o 1 -2 I :0= C) I U/ CURRENT LOCAL AGENCY FACILITY ID N N I APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRLDATE LOCATION CODE CENSUS TRACT F SUPERVISORS ISTRICT CODE 7 c�Ll' BUSINESS PLA YESCHECK# DATE FILED PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE /_/7 o df THIS FORM MUST BE ACCOMPANIED BY AT LEAST (i) OR MORE TANK PERMIT FORM 'B' APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLYvj . FORM A (3-2-8R)