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STATE OF CALIFORNI? WATER RESOURCES CONTROLBOARD f "` FORM `A': UNDERGROUND STORAGE TANK PROGRAM *"o SITE „ /FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z L/ COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE�R�1B�1Ef1�'L LOSED SITE I"a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / V j I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) C" FACILITY/SITE NAME _ �� jeAVV u CARE OF ADDRESS INFORMATION ADDRESS 7 NEAREST CROSS STREET to irgicate ❑ PAR7NEASHIP ❑ 57VEAGENU ORPOA 70 [ILOCALAGENCY ClFEOER L AGENCY V" l.iW {/Ifs INDIVIDUAL ❑ COUNDAGENCY CITU NAME / STATE ZIP CODE / M CODE�YTYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IID•# 5S�❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS or ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA GOD DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE rFc K ! & 14'ik a Inn V Zo ' — -5S'6 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(/ST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME �. yl CARE OF ADDRESS INFORMATION PA MAILING or STREET ADDRESSK ✓Box tointlicate ❑ PARTNERSHIP ❑ STATE-AGENCY / O I( �D Cl CORPORATION [ILOCAL-AGENCY ElFEDERAL-AGENCY F� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME r� STATE ZIP GODS J vv HONE N,WITH A DE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME & ! CARE OF ADDRESS INFORMATION alAq MAILING or STREET ADDRESS -/Box Lo,rrd,cWe ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ 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. ❑ II.v 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 N JURISDICTION N AGENCY R FACILITY ID N N of TANKS at SITE ® = = 16o Iq I 2Fl 101da CURRENT LOCAL AGENCY F,ZI Y ID' � APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER K CI PERMIT APPROVAL DATE PERMIT EXPIRATI NDATE i [CHECK OCATION CODE CENSUS TRACT�ryMy SUPERVISOR-DI TRICT CODE BUSINESS PLAN FILED DATE FILED T� YES � NO * PERMIT AMOUNT SURCHARG AMOUNT FEE CODE RECEIPTX BY: / 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. / FORM A(3-2-88) 'VA11VJ// • DATA PROCESSING COPY