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STATE OF CALIFORMA WATER RESOURCES CONTROL BOARD r FORM `A': °` UNDERGROUND STORAGE TANK PROGRAM = " xo SITJ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I z COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IV ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z O'x I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 7 C> FACILITY/SITE NAM ^^ CARE OF ADDRESS INFORMATION p 'S 1`JIRIBUTIN (fix AD RESZO W. NE�REST CCROSSS STREET ✓Box la Ydidile ❑ PARTNERSHIP 11 STAT&AGENCY CORPORATION 11FEGER LAG NC WlAESP 1, (TON11 INDIVIDUAL ❑ COUNTY AGENCY CITY! ME_C)CK—r0� STATE CA (—�12O3 l2Ll"I JE 0.WITH AREA O�E�� TYPE OF BUUSINESS'. 2 DISTRIBUTOR [:] 4 ROCESSOR ✓Box it INDIAN EPA ID X RESERVATION or X of TANK's 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS$ITE O EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE k;L�LLEP, AL Zog_4(Dto-C819(o nAmE NIGHTS: NAME(UST,FI ST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAE q/NION ILE 60, 0CARE OF ADDRESS INFORMATION \ J , MAILINGor STBEETADDRESS , w ee EM Sr ✓Box to indicate 11 PARTNERSHIP ❑ STATE-AGENCY �'Z� ❑ CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY �J ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAT ZIP Cg5Z03 �Z NE WITHAREA C�E 3 STOCICrt 0 N 9Y/8 Z III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAM pWt) -0 ,5TRIBuTI1J � CARE Of ADDRESS INFORMATION I , MAILING O EETADORE D^ �� ✓Box toindicate 11 PARTNERSHIP 11STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY FEDERAL-AGENCY 1 O \ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME�� kl To IIIII STFIEC ZIPqDE /'1 / HONE If WITH AREA CODE� IV. LEGAL NOTIFICATION AND BILLING ADDRESS F✓ /\J /If/lJ—I/LJ CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ it. ❑ III. Tr 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 R JURISDICTION M AGENCY X FACILITY ID X X of TANKS at SITE ml = = 101011= I 1 1 1_61 UTa7 AGENCY FACILITY IDX APPROVED BY NAME PHONE p WITH AREA CODE S 17 13 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE D+\ _I LOCATOION CODE CENSUS TRACT NO SUPERVISOR-DISTRICT CODE BUSINES BUSINESS PUN S N F❑ILEO NO ❑ DATE FILED `11 CHECK# I PECRRJ/MTAAMOC(UUNT SURCHARGE AMOUNT FEE CODE RECEIPTMmy:. LAI 1to`1o� �L� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI. iIS IS A CHANGE OF SITE INFORMATIONONLj,, \`T\ FORM A(3-2-88) C \ DATA PROCESSING COPY V\