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/mos- �5f�'iui�y'lM1f'\ STATE OF CALIFORNI9 WATER RESOURCES CONTROMBOARD A FORM `A': UNDERGROUND STORAGE TANK PROGRAM z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION dv IC EACOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 9 r I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CJi FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS ers vi LL NEAREST CROSS STREET ✓BOPiRimk 0 PA IP 0 STATE il(o555 / N So C�N ❑ CORPORATION OG4l AGENCY ❑ FEOEAAI AGENCY V J Qd ❑ INNNIOUAL ❑ COUNTI-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 2)4CY CA y/,cLf " 3 i-a13 TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR Box if RESERVATION or ❑DIAN EPA D p - `�R— ( 1 /^, n S� AT THIS SITE ❑ 1 GASSTATION ❑ 3 FARM ER TRUST LANDS W �`i� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE CDL S 1<Cr.1 -O)3� NIGHTS: NAME(LAS ,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 5ck,� A,,- Z MAILING or STREET ADDRESS -/Box to md,Y.te ❑ PARTNERSHIP 0 STATEAGENCY Cl CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �Y MAILING or STREET ADDRESS ✓Box tolntlicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE it.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: L II. ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME FRI TEDBSIGNATURE) DATE LOCAL AGENCY USE ONL COUNTY M JURISDICTI N M AGENCY# FACILITY ID If If of TANKS BI SITE 3I I I 11 -7 1 L� CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE LIA+�c PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE ICED .�/( � .1_�I YES NO 3 t 61 CHECK# PERMIT AMOUNT v SURCHARGEEI'AMOUNT FEE CODE RECEIPT# 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) �,\�\/1 DATA PROCESSING COPY