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STATE OF CALIFORNIR-' WATER RESOURCES CONTROL BOARD FORM `A': �.�,>' •, I UNDERGROUND STORAGE TANK PROGRAM =" o S� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Io COMPLETE THIS FORM FOR EACH FACILITY/SITE `"�•ow"—`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY SITE I"+ ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 1ruclCinq ADDRESS NEAREST CROSS STREET ✓ kik 0 PARTNBRNIP 0 STATE-AGENCY Alli L LOB'OAATION 0 LOX ABDO 0 FEDERk AGM L ❑ INONIDOAL 0 CIXN1Y-AGENC'Y CITY NAME STATE ZIP CODE - 5 E PHON p,WITH AREA CODE CA Sa05ab?ATTHIS 3 5doo TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Be.it INDIAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM �'SSTHER TRUSTYLANDS ATION dr ❑ ISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME GOuS e S ' �O d� PHONE X H-6("DE DAYS. NAME(LAST,F ,) PHONE aH AREA CODE NIGHTS: NAME LAST,FIRST) HONEp WITH AREA CODE NIGHTS NAME(LAST,FI RST) `•I^PHONEp WITH AVREA CODE ao Y6a —, (e b II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION cc . huGf-�r MAILIrN'�Jor STREET AD ESS _ ✓ toindicateTIO 0 PARTNERSHIP 0 STATEAGENCY T,S3 T S O CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY D 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAMESTATE ZIP CQDE O� PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) 5 NAME CARE OF ADDRESS INFORMATION S Ce�vyL2 cc S W MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. IIL❑ I 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 R AGENCY N FACILITY ID M B of TANKS AI SITE [au 1411 / / D 10o CURRENT LOCAL AOENCY FACILITY IDX APPROVED BY NAME T PHONE X WITH AREA CODE d 31 X� PERMIT NUMBER - PERMIT APPROVAL DATE PE MIT EXPIRATION DATE IS l2 j LOCATION CODE CENS-1!J$TRACTy,/`) SUPERVIS R-DISTRIOT CODE BUSINESS PLAN FILED DATE FILED (y O I lam{ 3 A U D a YES � NO 3 A 9 Q �J CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-83) �,,.Y DATA PROCESSING COPY `�