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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A#: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G 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 ❑F AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION al ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAIVE CARE Of ADDRESS INFORMATION 1-4 71 iP 11� ADDR/ESS NEAREST CROSS STREET ✓Fa VMouK ❑ PARIER9f ❑ STATE AGDO oMVMTON o m �fryLY ❑ FF ER4 ArJNY Am"GTY NAME STATE ZIP CODE SITE PHONE 1.WITH AREA CODE S�v 7 I CA ��i v (urr) Orli/ -Z TYPE OF SINESS. ❑Z DISTRDUTOR ❑/PROCESSOR ✓Boa A INDIAN EPA 10 1 RESERVATION or Fol TANK'F 1 GMSIATXIN ❑7 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST( PHONE F WITH AREA CODE DAYS. NAME(UST,FIRST) PHONE M WITH AREA CODE , 4/_L 7l� G fS Czoa)4�1�1 56 7 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE M WITH AREA CODE II. PROPERTY OWNER INFORMATION 6 ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓BOM Io atowale 13 PARTNERSHIP ❑ STATE-AGENCY /!d �/C/�L�/ ❑ INDIVIDUAL 13 0 LOCAL-AGENCY 13 COUNTY-AGENCY ❑ FSDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AR CODE 4 zc+z! 4`/4' f6-77 Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME -e-A-0. DARE OF ADDRESS INFORMATION MAL/IL/UNG a STREET ADDRESS ✓BOM Io inal"re 13 PARTNERSHIP ❑ STATE-AGENCY L C0 7 s /2� � ❑ CORPORATION ❑ LOCAL-AGENCY 1) FEDERAL AGENCY �� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 1,WITH AREP CODE _-:R-�4oL-7 nl Clw IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADORNS$SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY01 JURISDICTION Y AGENCYAT FACILITY ID 0 F of TANKS SI SITE = = = 1 odz S�- 1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE "4to,&1L_ GO PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTS SUPERVISOR-DISTRICT CODE BUSINESS PINI FILED DATE FW LOCATION D z 3. YES C] NO ❑ Z ZS G/ CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# \�^^\\THIS FORM MUST BE ACCOMPANIED BY AT LF- - •I)OR MORE TANK PERMR FORM 'B'APPLICATION(' 'NLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. A132VB\�\��. � •,.. � I1 v