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STATE OF CALIFORN WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM � o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION c�Fo�,A6 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 NTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �'Il I 0 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION FACILITY/SITE NAME t_tGA V�IEST�Z� R L- 1k �� ADDRESS NEAREST CROSS STREET ✓ oMiomdicate ❑ PAATNEASAIP ❑ Sl'ATEAGENCY f�COHPQAATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY S. _ R a ❑ INDIVIDUAL ❑ COUNTY-AGENCY CT7 CITY NAME J STATE ZIP CODE SITE PHONE ti,WITH AREA CODE ' C_ CA `x)52 C2-C3) 441 -� TYPE OF BUSINESS: 2 DISTRIBUTOR El 4 PROCESSOR ✓Dox it INDIAN EPA ID h #of TANK's 5 OTHER RESERVATION or ❑ AT THIS SITE 1 GASSTATION � 3 FARM ® TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DRYS', NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS', NAME(LAST,FIRST) PHONE u WITH AREA CODE Z11-0 11 PHONE#WITH AREA CODE NIGHTS, NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS', NAME(LAST,FIRST) IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME 'foo �✓�a To indicate Li PARTNERSHIP MAILING or STREET ADDRESS 11 57ATE-AGENCY L+�COxRPORATION ❑ LOCAL-AGENCY Q FEDERAL-AGENCY p , I ❑ INDIVIDUAL ❑ COUNTY-AGENCY F \! STATE ZIP CODE PHONE N.WITH AREA CODE CITY NAME A 97y(p2V H►4� 5`i9 -meq ng III. TANK OWNER INFORMATION & ADDRESS -- (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME E C. ES ill. C�IzouP 1+.1C. 3co V v MAILING or STREET ADDRESS ✓Box to indicate Q PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY r� rz—AvikiI E-i- &V i. ❑ INDIVIDUAL ❑ COUNTY-AGENY JJ STATE ZIP CODE �_�T ,WITH AREA CODE CITY NAMEt,�zF 1 �} ' '-19 ©909 1V. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(t)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, APPLICANTS NAME(PRINTED&SIGNATURE) 1 DATE / FtzAvl K W Alm t_A,C --I/� !/�� (p /& I SS LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE H El 1010 j C� 1 APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILIITjY ID# 1 Vl / p V1 1 J rCHECK UMBER PERMIT APPROVAL DATE PERMIT EXPIRAThON DATE ��ON CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDZ330YES NO# PERMIT AMOUNT SURCHA G AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-86) DATA PROCESSING COPY