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STATE OF CALIFORIw WATER RESOURCES CONTFfI'!L BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE �r 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 L] 7 TLV CLOSED SITE ONE ITEM V2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z 10 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF DDRESSINFORMATION ADDRESS a N E ✓fkxlo 6ule ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCYF Sun GEHa ❑ INDIVIDUAL ❑ CGGNN�AGENCY .� CITY NAME - STATE ZIP ODE I E PHO E If,WITH AREA CODE •Vitt Ott CA S"Z�l o - 2 TYPE OF BUSINESS 2 DISTRIBUTOR 4 P OCESSOR ✓Box if INDIAN EPA I d K of TANK's /1 ❑ 1 GAS STATION ❑ 3 FARM ❑ OTHER RESERVATION o ❑ AT THIS SITE V- EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIR�T) n PHONE N WITH ARE CCOE DAYS: NAM .(L ST,FIRST) PHgWE I WITH AREA CODE /L�AAZ AJ C. Z,a 3 3"0'Z� S �p� J(/A NIGHTS- NAME(LA FIRST) PHONE k WITH AREA CODE NIGHTS N E(LAST,FIRST) O E N WITH AREA CODE /3a stn -3 8/ S' A, II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMECARE OF DDRESS INFORMATION AN M N[)G�oJr STR.,+�T ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ♦ `� IJ q 0 ❑ NDIIVDUALION 11 LOCAL-AGENCY❑ COUNTY-AGENCY F RAL- GENGV Cry b 1 STATE ZIPI Zv PHONE k.WITH AREA / III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) ab NAME CARE OF D RESS INFORMATION MAILING(c STREET A DRESS ✓Bo to li tldw to ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY FEDERA -AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY fa Una& CITY NA.M STAT ZIP C D PHONE H AREA CODE IA IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 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 LOCAL AGENCY USE ONLY COUNTY K JURISDICTION K AGENCY K FACILITY IDK K o1 TANKS at SITE 1010 13 i dl D 16 3 CURRENT LOCAL AGE Y FACILITY ID K 71i: ME PHONE K WITH AREA CODE •v r(Tt PERMIT NUMBER I ROVA DATE PERMIT EXPIRATION DATE L DE CENSUS TRACCTT/K� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D T FI.C lJCrEs No PERMIT AMOUNT SURCNA G AMOUNT FEE CODE RECEIPT K by: 1 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. FORMA(3-2-88) cJ DATA PROCESSING COPY �,/