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.y. I STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE 1 NEW PERMIT 3 RENEWAL PERMIT T MARK ONLY F-15 CHANGE OF INFORMATION LY CLOSED SITE❑ ❑ 4 � ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME 1 h� I I�as �f / CARE OF ADDRESS INFORMATION o t4 ADDRESS NF,ARST'�CjryOSSSTRE ✓3abWM ❑ PARTNERSHIP ❑ STATE AGENCY 7. I S . L£1/Tr✓lL WQ$l�IN ❑ INDDRIDUAl. o COU�im�AGENCY ❑ FEDERAL AGENCY CITY NAME STATE ZIP CODE SITE PHONE*,WITH AREA CODE CA q 51'a TYPEOFBUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR 'INDIAN EPA ID a #oITANK's RESE✓eazRVATION or AT THIS SITE ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS/ HWITH AREA DAYS, N IR P—HONSEM WITH AREA CODE nLO � -5-6KO ? f / -S NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIR ) I, PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF AD RESS INFORMATION I 2 6LArJ f LINes 7-n►� MAILING or STREET AD ESS �^ ox tc intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY I j,, e'/J CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY /24411/ jq4 V F/K^ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME , STAT ZIP CODE PHONE .WITH AREA CODE P�nev(IX �Z 950-7-7 UK III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME MI 1 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ ox to intlicate ❑ PARTNERSHIP Cl STATE-AGENCY 16 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE I,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: I. IV it. ❑ 111.[:1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. I. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE I'I LOCAL AGENCY USE ONLY COUNTY# JURISDICTION Al AGENCY# FACILITY ID# Al of TANKS at SITE v / a01 1 10101ol/ CURRENT LOCAL AGENCY FACILITY ION APPROVED BY NAME PHONE N WITH AREA CODE G PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L DE CENSUS TRACT#( SUPER ISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Z 3 8� a,O YES E] NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT IF 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(3-2-115) + DATA PROCESSING COPY .,,r