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oT STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE CR��FORR�� MARK ONLY ❑ 1 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 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BRPMr9e D FIATNBGW D STATE,IGENY 2 J5. "442-MA W Q1�(>C,E GLE D COWDu.� D LmKAGD a D FEDERa1GEU CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 5 wr0e_K rwA CA Q 44& - 1 TYPE OF BUSINESS-. ❑2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box A INDIAN EPA ID N N of TANK'N RESERVATION or ❑ AT TRIS SITE O ❑ 1 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 N WITH AREA CODE 0or� t E (2oa) aka- fab E12N T M (Zoq - I 1 NIGHTS'. NAME( ST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to irud,.te D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,rd,cele D PARTNERSHIP D STATE AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.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. ❑ 11. ❑ 111.❑ 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 COUNTY B JURISDICTION N AGENCY M FACILITY ID R S of TANKS at SITE " 3z 001 os I 1 Uvoo CURRENT LOCAL AGENCY FACILITY ID N LAEED PHONE N WITH AREA CODE 4om-n PERMIT NUMBER PERMIT APPROVAL DATET EXPIRATION DATE LOCATION CODE CENSUS TRACTN SIl►ERVISOR-DESS PLAN FILED DATE FILED 3 OCL. YES NO /I/ZF /QC{oCHECK Y PERMIT AMOUNT SURCHARGE ARECEIPT N BY: �Y U THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM B'APPLICATKIw(S), UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. \ (1 FORM A(3-2-83) J v