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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMV m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r �0 o 's COMPLETE THIS FORM FOR EACH F CILITY/SITE 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 17 7 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME )(7, r CARE OF ADDRESS INFORMATION J % da T®;v j T C'? CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY MAILING or STREET ADDRESS ❑ INDIVIDUAL ❑ COUNTY -AGENCY ADDRESS STATE NEAREST CROSS STREET ✓ dic11 ❑ PARTNERSHIP ❑ STATE -AGENCY , , / / j J 2 d V✓ a 4 Lam% I o ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME Cl INDIVIDUAL Cl OUNTY AGENCY ❑ FEDERAL -AGENCY Cl CITY NAME PHONE #, WITH AREA CODE STATE ZIP CODE SITE PHONE #, WITH AREA CODE BY: CA 4's�s a 63-w/l/ TYPE OF a NESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID # of TNK's 1 GAS STATION 3 FARM 5 OTHER ❑ ❑ RESERVATION or TRUST LANDS El L l�r AT T HAS SITE ,3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) &,0,? HONE # WITH AREA CODE -4r&3 S o " AY, _S? I." 0 /--l'oAldo _ V//Yl NIGHTS: NAME (LAST, FIRST) PHONE fWITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME )(7, r CARE OF ADDRESS INFORMATION J % da T®;v / eJuso CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY MAILING or STREET ADDRESS ❑ INDIVIDUAL ❑ COUNTY -AGENCY ✓ BDrf(o indicate Cl PARTNERSHIP ❑ STATE -AGENCY STATE /be MItORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY 3 -, vi ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME DATE FILED.3 STATE ZIP CODE PHONE #, WITH AREA CODE FEE CODE %r BY: III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓,Sefto indicate ElPARTNERSHIP ElSTATE-AGENCY CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY FERMITNUMBER ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS I CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. �z II. ❑ III. ❑ I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY JURISDICTION # I I I I AGENCY # L-LIXT741 FACILITYID# (-� # of TANKS at SITE d' L-01 L/ AfGEENNCY FA(�CILITY IDC# ��\ 1� �J APPROVED BY NAME PHONE #WITH AREA CODE FERMITNUMBER PERMIT APPROVAL DATE DATE CENSUS TRACT # SUPERVISOR -DISTRICT CODE 0� 3 BUSINESSYPS N FILED NO ❑ ❑ DATE FILED.3 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. FORMA (3-2-88) ,�8) DATA PROCESSING COPY ( M �j 46 �y