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STATE OF CALIFORNIA" WATER RESOURCES CONTROL—BOARD FORM `A':� =mo UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY El 1/46 PERMIT F-13 RENEWALPERMIT E] 5 CHANGE OF INFORMATION ❑ 7 WILY CLOSED SITE N ONE ITEM 2 INTERIM PERMIT 1714 AMENDEDPERMIT E]6 TEMPORARY SITE CLOSURE 0 4 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) O FACILITY/SITE NAME ' CARE OF ADDRESS INFORMATION I !C / nj " �/2V"7/ad ADDRESS NEAREST CROSS STREET ✓BN IoiNgk D PARTNERSHIP D STATE-AGBWY (� 2 51 EL D0m,90 DD IN�WI DD ��T" ❑ R AGD Y CITY NAME5;/k � STATE zipifj�/� SITE PHONE p,WITH AREA CODE CA TYPE OF BUSINESS' ❑ p DISTRIBUTOR ❑ 4 ESSOR -/Box N INDIAN EPA IDN SS N W TAI K's D / RESERVATION or ❑ AT THIS SITE ❑1 GAS STATION ❑3 FARM 5 OTHER TRUSTIANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST FIRST) PHONE If WITH AREA CODE clC �g/ S`6Lca� �a —d2-1-00 40 NIGHTS: NAME(LAST.FIRST)p� PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE i S! Iwa- I 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION acme a s -t MAILING or STREET ADDRESS JBox to intlicale D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIPCOE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION u 7"t 411.5 a,erfl-7iv� MAILING or STREET ADDRESS / np x to intlicete ❑ PARTNERSHIP D STATE-AGENCY O I 6 RiV D INDRVIDUALIDN D COUNTY AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA COD 's-Tv-W �Pr 5 24 ZG —d IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ Ill. 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 p JURISDICTION N AGENCY 4 FACILITY ID 4 4 of TANKS at SITE ® 10 �) v 01/ 1 CURRENT LOCAL AGENCY FACILITY I p APPROVED BY NAME PHONE*WITH AREA CODE 4 L+<'7 Q 61//019"1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE /Z Z7 Tld� LOCATION CODE CENSUS TRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED OYES NO ECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: / MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \ DATA PROCESSING COPY /\)