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STATE OF CALIFORNIP WATER RESOURCES CONTRONIOARD W: Asa FORM ': . �� UNDERGROUND STORAGE TANK PROGRAM =" ALL SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONMQI ; COMPLETE THIS FORM FOR EACH FACILITY/SITE `"�!•a=�`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION !fa SED SITEONE ITEM ❑ 2 INTERIM PERMIT El4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) I FACILITY/SITE NAME � AtAi 1.��1/�(/ CARE QE ADDRESS INFORMA � TI N u,2- l NEAREST CROSS STREET Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY N ADDRESS C E' AU, ADORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY MOMDUAL ❑ COUNTY- AGENCY CITY,NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE v/I CA 3(7-(0106 TYPE OF BUSINESS. ❑ DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID Al RESERVATION or Rol TANK'a ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ k)0k)E AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE It WITH AREA CODE DAYS: NAM W ST.FIRST) PHOVE#WITH AREA CODE S S'1A NIGHTS'. N MER ST,FIRST) EfONE�WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHpNE#WITH AREA CODE NI_/l13 i?-6/a 51A .1�/T„1 11. PROP TY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME y/y� RE CAO ADDRESS INFORMATION V � A MAILINGo,STREETADDRESS -/Box to indicate 13 PARTNERSHIP ❑ STATE-AGENCY L) 8A ❑�EORPORATION LOCALAGENCY ElFEDERAL-AGENCYVVV B INDIVIDUAL ❑ COUNTY-AGENCY CITY NAM STATE ZIP CODE PHONE q,WITH AREA CODE U/oo 4— S +4 Sal III. TANK OWNER INFORMATI N & ADDRESS - (MUST BE COMPLETED) NAME CAREOFDRESS INFORMATION 5 l4 SA MAILINGor STREET ADDRE`S'S �✓Box to indicate 11PARTNERSHIP [ISTATE-AGENCY ORPORAT�VV O v v IJllN DIIVIDUALION 11 LOCAL AGENCY El COUNTY'-AGENCY FEDERALAGENCY CITY NAME STATE ZIP CODF1 PHONE a,WI H AREA CODE Gvoad.bvl L S S A s�A 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 TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It AGENCY# FACILITY ID# #of TANKS at SITE Eoil = = 10101 1 010 le) 1 o CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA N CODE CENSUS TRAC;N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F�EDp p/y L/f\ (- YES [] NO � 7 /'L 00 CHII # PERMIT AMOUNT SURC A GEAMOUNT FEE CODE RECEIPT# BY: 1 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) L 1 DATA PROCESSING COPY • S