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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARDA FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =" a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `�/ COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE O ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) c0 FACILIT`Y/SSI�TE NAME ^ CARE OF ADDRESS INFORMATION ADDRESS,DLC k//L1'7 /Y1;1,�J�G% A1-/j ^NEAARESTT CROSS STREET n ✓lox loiNiCBle ❑ PARTNERSHIP ❑ STATE 36 9 W " W�l I � VE IS �K ❑ CG ORALION ❑ LOCAL AGENCY COUNTY AGENCY ❑ GEPAL AGENCY CITY NAME / 1 STATE ZIP CODE ITE PHO a,WITH AREA CODE Lo tb 1 r `T CA q S rL�l 2 209 3601 1132TYPE OF BUSINESS 2 DISTRIBUTOR 0 4 PROCESSOR ✓Box if INDIAN EPA ID N If of TANK's RESERVATION or AT THIS SITE 1 GAS STATION 3 FARM 21�10THER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) P ONE N WITH AREA CODE PF/T�[ R q)369 1132 AN = 1 7�L Sr�ntnl o� _36g' 11572 NIGHTSNAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME Up fW.p!� x�. )PCARE OF ADDRESS INFORMATION _ MAILING or STREET ADDRESS r ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ' p ('� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <Oo7, �vrr ( 1G � ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODEPHONE N,9IT AREA CODE /1 2— cam}- • 9 s_ Z00 1(�lll�,�n� 36 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION v�Un/I��'�. - . PATE MAILI G m STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP Cl STATE-AGENCY pO ' / n ice. ❑ O ..DUAL ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY y INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE "D/. 40 0 &ff IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 111 IL ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,I�nS TRUE AND CORRECT. APPLICANT'S NAME(P NTED&SIGNATURE) DAT J/O // _?0 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE 30 PERMI NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIONDATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (,1 3 _ 'zo YES [-] NO 1--) /(O/ LJ �V CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: �N v THIS FORM MUST BE ACCOMPANIED BY AT LEAST( R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) -1 DATA PROCESSING COPY