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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ""1J FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to COMPLETE THIS FORM FOR EAC FACILITY/SITE "'•�•"�" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PER N LY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) FACILITY/SITE NAM CARE OF ADDRESS INFORMATION �aMF Yu L ADDRESS ////�E'' Ani �j�1��// N EST CROSS STRE^FT l/BmbYNkae 0 PARINEWIP 0 STA7EAGENCf IZ !_ V/xV / a I (A7 I ❑ CORPORATION 13 ryip� 13 �ryOO 0 ��AGENCI CITU NAME (1 �� STATE ENCf 21P CODE SITE PHONE N,WITH AREA CODE J CA - S TYPE OF BUSINESS: ❑2DISTPoNITORROCESSOfl -/BOX#INDIAN EPA ID It '7 ❑ 1 GAS STATION ❑3FARM 1:65/OTHER TRUSTT LATNDS ION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N VITH AREA CODE U� NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) j NAME CARE OF ADDRESS INFORMATION 'TAM e.5 u ✓Ar4 MAILING or STREET ADDRESS .�� _ ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY //// ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY NP' 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME Ma4W4 ` _ STATE_ ZIP CODE _5 l/ PHONE If,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS/T7V-1 (MUST BE CL//OMM)PLETED)S7 S (� NAME ^ CARE OF ADDRESS INFORMATION `JQ MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE. ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ 11. ❑ 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) DATL" LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE I w-31 w,e s 2-A,-7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DAtE LOCATIONCOOECENSUSTRACCT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED w 73 0 0 �� YES E) 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. 9M A(3-258) --^r DATA PROCESSING COPY '�+