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STATE OF CALIFORA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM � p SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1. COMPLETE THIS FORM FOR EACH FACILITY/SITE `«,Fo a."-`" MARK ONLY/-I I—] I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUR 3 7 I.FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 10 FACILITY/SITE NAME !l CARE OF ADDRESS INFORMATION GO �'1NNck RQ`VSOL� (fs r" i✓CwK'S MA Jce7 10 SHIN e.t5�� N ADDRESS NEAREST CROSS STREET mirdiwle PARTNERSHIP ❑ SiAiEAGENCY '1 G �� GL_ CORPORATION ❑ LOCAL ❑ FEDERAL AGENCY d• C �--i ❑ wONIDUAL ❑ COUNT'AGENCY CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE 1 r�ac �( cA fI3 7� �S sq!! ,,5 F BUSINESS: ❑ p DISTRIBUTOR [:] 4 PROCESSOR ✓Box if INDIAN ID a RESERVATION ar (f/.J��' q of TANK's 1 GASSTATION ❑ 3 FARM -b'OTHEA TRUST LANDS ❑ \� AlolI AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) _DAYS NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE —� k4 pv I - S4 I-1 6 TS E(LAST,FIRST) ONE a WITH AREA CODE —NIGHTS'. NAME(LAST,FIRST) PHONE it WITH AREA CODE II. PROPERTY OWNER INFORMATIO & ADDRESS - (MUST BE COMPLETED) E n /p -CARE OF ADDRESS INFORMATION Pr A-c-1 ri - I d�..'1T1�"]s✓ (/.(J: �i LT/N)^ MAILING or STREET ADDRESS to indicate 11PARTNERSHIP LISTATE-AGENCY IDR �- ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY C ❑ INDIVIDUAL ❑ COUNTYAGENCY VTY NAME RATE ODE PiEr5NE a,WITH AREA CODE / IJfc,awi I SCv C f� al cE IoS' III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) E '111 ADDRESS INFORMATION �c�u tfierry ��cl r�,� I�au sPanf�4 1J j, MW 4 / �crnryt 1007 s, 1= (LING or STREET ADDRESS U ✓ indicate PAR NERSHIP STATE AGENCY BLCORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY TY NAME / TE I 2,rPZOCE E a.WITH AREA CODE 7 GLS L/ IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY OUNTY B JURISDICTION# AGENCY M to FACILITY ID At ,(o# I TANKS at SITE C RENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 'PERMIT NUMBER Re ll IT APPROVAL PATE PERMIT EXPIRATION DATE rCHECTION CODE SUS TRACT p UPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D ILErD7 pp C� 7• L� �- YES ❑ K## PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. FORMA(3-2-88) 0 DATA PROCESSING COPY 0