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MATE F CALI I TER RESOURCES CONTROL BOARD FORM `A': N R ROUND STORAGE TANK PROGRAM #TE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT JAL 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q Q 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 1 j eggug SM.LSP_LoP0P,-T 61EVC44,(A ADDRESS NEAREST CROSS STREET ✓ mir rte Cl PARTNERSHIP ClSTATE-AGENCY COIVIDRPORATION ❑ LOCAL-AGENCY C3FEDERAL-AGENCY INDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE S-rocyllW4 CA �)C.7210 lezn) TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA 10 N #of TANK's RESERVATION orF7 �,'o 0,820,822.71?. 050 AT THIS SITE ��E El GAS STATION ❑3 FARM 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) _ PHONE It W JTHMRZONpa � (NIGHTS: NAME(LAST,FIRST) J PHONE N WITH AREA CODE NIGHTS: NAME(LASr,FIRST) PHONE N WITH AREA CODE 14&N.YAO REY C S2- t3 S I.MC-ALe - oSS il. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 0500kLON A MAILING or STREET AODRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY rbbx ❑GMSS ORPORATION ❑ COUNTY-AGENCY AGENCY 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE I L-prfAs CA 35 NA NK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) AME CARE OF ADDRESS INFORMATION (J b LU - MAILING or STREET ADDRESS �{ ✓Box to indicate ❑ PARTNERSHIP (ISTATE-AGENCY 1 S E� t ❑ CORPORATION ❑ LOCAL-AGENCY FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 1.WITH AREA CODE t4ewPoR-t bePlCAA Com+ ")24.60 C714 851-2259 IV. LEGAL NOTIFICATION AND BJILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLI : I. ❑ if. ❑ III• THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDG ECT. APPLI IT'S NAME(PRI TED&SIGNATURE) DATE LA9AY SELL- LOCAL A Y U ONLY COUNTY# JURISDICTION At AGENCY# FACILITY ID# #of TANKS at SITE 1 -2 k _F] LL 1 6=) CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME � [ ;I PHONE k 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 01)OR MORE TANK PERMIT FORM `B'APPLICATION( LESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY F' A I I,- 19213 -- ,•IwI'd