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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM W Y ^gym SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS G COMPLETE THIS FORM FOR EACH FACILITY/SITE C\PORN P MARK ONLY ❑ I 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 0 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Gv �Dds� 5�f2 ,.(LU ADDRESS v NEAREST CROSS STREET v/Box to indicate El PARTNERSHIP El STATE AGENCY s. �f�� CD� G�/�- E]El ElLOCAL-AGENCY ElFEDERAL-AGENCY L�� ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE 44- �DGfCTC�� CA Z TYPE OF BUSINESS: ❑ p DISTRIBUTOR 4 ESSOR ✓Box if INDIAN EPA ID a 7ATTTHIS K's TRUST LANDS VATION or ❑ ' ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE e_-ALDG'ELL cz,4L'Te�4 46of—663 NIGHTSNAME(LAST.FIRST) 011 PHONE#WITH AREA CODE I NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY w/_// ElCORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY lel�'_I GLJ / !/(T�� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE 1 PHONE# WITH AREA CODE sw /Wr-,ro I I c? 4 14 o3 s2i - Z44i< III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAPE nom} CARE OF ADDRESS INFORMATION ba /d/4 lj ✓DC4 "44 H-� o'y4/raW(P ?Z-. MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNE SHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY P. D• ' I ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE �5r : ] IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE O 18rj6 I Lo I JH51 CURRENT OCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE >Qcvk o PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE LED U l 23 YES NO All, CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 71!E_CODE RECEIPT# BY: i THIS FORM MUST BE ACCOMPANIED BY AT LEAST f"01 MORE TANK PERMIT FORM `B'APPLICATION(S►, UNI FqS THIS IS A CHANGE OF SITE INFORMATION ONLY. ORM A(3-2-88) DATA PROCESSING COPY