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AmwT'" `Mm -Wmp**RT rFNWV -y+'i"`' STATE OF CALIFORN„4 WATER RESOURCES CONTRuL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM V y� SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ';! COMPLETE THIS FORM FOR EACH FACILITY/SITE CqC FOpN`P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT PQ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE cr) r I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION aEAe0fJ c�9s ADDRESS /1 NEAREST CROSS STREET ✓ xtoindicate ❑ PARTNERSHIP 13STATE-AGENCY CIDO S• CAGao1CCE L.Avo E Atf CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME, STATE ZIP CODE SITE PHONE If,WITH AREA CODE LOgl CA g5,;)ga (20Q) X68 - 980) TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA iD a RESERVATION or #of TANK's m 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE 9 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE TH IZ C-O IJ Q A RBA2q 209 3108-%0 1 M A R_C C-T`T 1 C__)0uv (a04� 1013 —dS 3 7 NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE T"09Itj,0k36AQ6A0sa (atX1) 33 ^x"18] MAQQETT ( I W13 , 3g�1- .1-741 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �.Ll.'TRRt2 WrntINC SAN)OV ♦-TUFF MAILING or STREET ADDRESS ✓ ox to indicate E3PARTNERSHIP ElSTATE-AGENCY hd'CORPORAT5T 2,5 3rd S 1 11INDIIVIDUALION COUNTY-AGENCY ❑ FEDERAL-AGENCY CITY NAME STA E ZIP CODE PHONE#,WITH AREA CODE t•-1A�F0e.n (1,VA g3a30 (�)Dn) 583-S-S98 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF dADDRESS INFORMATION U_LT214YYtAa IAlec OWoV 4uf F MAILING or STREET1 '\ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Sas W �f�1 S LM'CORPORATION 1:1 LOCAL-AGENCY ❑ FEDERAL-AGENCY �3 T ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMESTATE ZIP CODE PHONE If,WITH AREA CODE aP,*�TaQA 0A 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. ❑ it. 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&SIG NA RE) DATE JAU,DY 91,Fc ate LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE m CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO ❑ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 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) DATA PROCESSING COPY