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STATE OF CALIFORNIS WATER RESOURCES CONTRO OARD FORM IA': UNDERGROUND STORAGE TANK PROGRAM = � o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMAUUTIZ?LlOSER SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE b V -4 co I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACILI ITE NAME ;-� 1 CARE OF ADDRESS INFORMATION im OVA RI!-.vm, i ADDRESS NEAREST ROSS STREET ✓Six, '6 1, '❑ PARTNERSHIP ❑ STATE AGENCY 1 . �( Wo t o ElLl CAAPOAATION ❑-LO ❑ FEREAAL AGENCY 5Ov) w N INDIVIDUALCOUNTY❑ AGENCY AGENCY CIN NAM STATE ZIP CODE SITE PI,HO1N N WITH AREA CODE p C�K40 V) CA N0 TYPE OF BUSINESS: ❑ @ DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # III of TANK's ^ ///1(//� 13 AT THIS SITE f ❑ i GASSTATION ❑ 3 FARM 5 OTHER TRUSRVIANDS or ❑ CH V M+ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIflST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Erlk Frye ri Zo�t NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME, 'L - "1/ sI- I'I va I ,xx CARE OF ADDRESS INFORMATION MAILING r ST ET AD RE V1 IR` L7l ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY }, LIQ ❑ CORPORATION Cl LOCAL AGENCY ❑ FEDERAL-AGENCY l 1y' /�((d Or�I d Q T%IIINDIVIDUAL Cl COUNTY-AGENCY /� ��T/� /E(� '/�/L y/' CITU ryAN1E O { IV l Ste-" \; 1G P,0 \"(N'f W 1 6RlP COLE / (f III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE If.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. ' (CANT'S NAME(PRINT D&SIGNATURE) DATE ijrluvI A, &avV o LOCAL AGENCY USE ONLY COUNTY k JURISDICTION If AGENCY R FACILITY ID 1f R of TANKS at SITE 3 qI I I _�,-Is aI L9 10 1 o 1 i CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE SFW L4 9 PER7CODECENSUS PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOT A! SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL�E`JDD CHT SURCHARGE AMOUNT FEE CODE YES ❑RECEIPT YG ❑ BY: _ �_ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLIII THIS IS A CHANGE OF SITE INFORMATION ONLY \ FORM A(3-2-88) • DATA PROCESSING COPY