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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 m : IIZO G COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 9 5 CHANGE OF INFORMATION ❑ 7 PERMANEN YCLOSEDSITE ONE ITEM ❑Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE s/ —4 Ln I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME I- p CARE OF ADDRESS INFORMATION r o� Nr� nG vler i ADDRESS �`I.��{/p NEAREST CROSSSTREET b[Gnk 0 PAATMI&W 0 STATE'AGD& ,2150 cla ,`-r ' / ($ 1n' CD9P�A,ON ❑ LOGLAGENLY 0 FEDI LAGENIX \/It {. Yr. 0 INOMGOAL 0 I;(MMttAGBIC/ I CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE c CA 0?-7fle-51yo TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Boz d INDIAN EPA ID x RESERVATION or N of TANK'N ❑ I GAS STATION [:] 3 FARM 50THER TRUST LANDS ❑ 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 WITH AREA CODE Ker CA e> 20q - - NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE . NAME(LAST,FIRST) PHONE N WITH AREA CODE Ke -5z/01 II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME DARE OF ADDRESS INFORMATION New at d iw— fa Mo4or5 MAILING or STREET ADDRESS _✓.Roxto'ndicate 0 PARTNERSHIP 0 STATE-AGENCY pNIo •CORPORATION 0 LOCAL-AGENCY 11 FEDERAL-AGENCY l/0 fe _ _ ( ❑ INDIVIDUAL 0 COUNTY-AGENCY CITUN O& STTgE I ZIP CODE r7 PHO =.`ITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) 1— NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 13 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: Ilef 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCYA, FACILITY IDN N of TANKS at SITE OCURR® 10 10 O 10 10 1:0:1— CURRENT ENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE /UE(.uf102 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 23 9`0 YES NO 21161901 CH KN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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 4FOtAk(3-2-M) DATA PROCESSING COPY ,,,�