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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY'-- MEQ _ I OF ADORE53INFORMATION ADDRESS NEA EST CROSS STREET ✓I7R Ip YdRlg pMT*T" ❑ STATE AGENCY 1 h� ❑ oJrPORAnox ❑ LOCALAGi ❑ FMIALAGOlLY C3INGmnw ❑ Colim AMC( CITY NAME STATE ZIP CODE I SITE P ONE M.WITH AREA CODE 601 CA �Z d 3 �- TYPE OF BUSINESS. ❑2 STRIBUTOR ❑ 4 PROCESSOR ✓Box It INDIAN EPA ID a ❑ 1 GAS STATION 03 FARM ❑ 5 OTHER TRUSTVATION LANDS or ❑ F o1 SITE 0 AT THANHIS 817E EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) AYSNAMW D ) PHONE N WITH AREA CODE DAYS: N (LAST.FIRST) PH p WITH AREA CODE ✓L�[c� �� 3�9 -Y-/L A4 SQ NIGHT NAME(LAST.FIRST) PHONE Y WITH AREA CODE NIGHTS..- NAME(UST.FIRST) O E p WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) W/I NAM 2 � CARE OF ADDRESS INFORMATION MAILING of STREETADDRESS ✓Box to iiWbete ❑ PARTNERSHIP ❑ STATE-AGENCY ODn / ❑ CORPORATION ❑ LOCAL-AGENCY ClFEDERAL-AGENCY Y_ ` Nt ❑ INDIVIDUAL O 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 15 A MAILING or STREET ADDRESS ✓Box N,inEicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL Cl 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: I. 1L ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION B AGENCY M FACILITY ID R R o1 TANKS BI SITE 00 1 Lli= 101010 lol CURRENT LOC��%NCY FACILITY ID N APPgOYED BY NAME/D PHONE N WITH MEA CODE PERMIT NUMBER PERMIT APPROVAL DATE Ml— PERMIT EXPIRATION DATE LcmE .Nc"DE CENSUSTRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED�}} YES NOPERMIT AMOUNT SUR ROE AMOUNT FEE CODE RECEIPT F • . THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88),