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STATE OF CALIFORN WATER RESOURCES CONTROL BOARD FORM"A': UNDERGROUND STORAGE TANK PROGRAM SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 7COMPLETE THIS FORM FOR EACH FACILITY/SITE C41 FORK P 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 g'D d I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) C j FACILITY/ ITE NAME CARE OF ADDRESS INFORMATION rnGp W . ADDRESS NEAREST CROSS STREET ✓Boytoi6we Cl PARTNERSHIP ElSTATEAGENCY ClCORPORATION 1:1 LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE 71P CODE SITE PHONE#,WITH AREA CODE C� CA U 0,0 q TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 ESSOR --/Box ii INDIAN EPA ID # RESE❑ ❑ � TRUSTVLANDS ATION or ❑ #of HIS SITE 3 1 GAS STATION 3 FARM 5 OTHER AT THIS 517E EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) _ PH E TH AREA CODE �,. s (aaR Y - 3 b :ft r — 14if O NIGHTS: NAME(LAST,FIRST) PHONE H WITH AREA CODE NIGHTS: N (LAST,FIRS ONE#WITH AREA CODE Sr i (aa� '4 ?'-2?2 Ca�9� 3&9�379 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET A KESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY r ❑ CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY 15, ♦ ❑ INDIVIDUAL ❑ COUNTY-AGENCY i CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE ac C 64 12 5212 D Ill. TANK OWNER INFOFAATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION D G�1 MAILING or STREET ADO ESS ✓Box to indicate (:1 PARTNERSHIP ClSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY j CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE I IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ 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 8 SIGNATURE) DATE . LOCAL AGENCY USE ONLY �CO�UN�TYY### JURISDICTION# AGENCY# FA = #o1 TANKS at SITE 71 161 6 _� CURRENT LOCAL AGENCY FACILITY ID N__ APPROVED BY NAME PHONE N WITH AREA CODE PERMIT N(JIAdEk PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE YES ❑ NO ❑ J 7 y CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 7EE CODE RECEIPT N B Ii I THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11%OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . FORM A(3-2-88) j DATA PROCESSING COPY '�✓ f