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i STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': _ UNDERGROUND STORAGE ANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/ r PERMIT APPLICATION10 COMPLETE THIS FORM FOR EA FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ P O TLY CLOSED SITE ONE ITEM F-] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — MUST BE COMPLETED) OD FACILITY/SITE NAME // CARE OF ADDRESS INFORMATION ,e A/e soy I ATEAGENCY ADDRESS NEAREST CROSS TR$ EEJ, A ❑ � N ❑ LOCpARENEAPGGOV D ORDE_AGENCY l/,)f/)OJ a��('/�(�/ ❑ INGMOUPL ❑ COUNT!AGENCY CITY NAME STATE ZIP CODE / SITE PHONE M.WITH AREA CODE S CA s 24Vh Z P/W/3Z TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑d PROCESSOR I ✓Box if INDIAN EPA ID N It OI TANKYRESE �J ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or ❑ AT THIS SITE v EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS N ME}LAST,FIRSTI p'- 1 PHONE X WITH AREA CODE DAY NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST, IRST) PHONE 4 WITH AREA CODE NIGMTS NAME(LAST, ST) PHONE M WITH AREA CODE L( II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) I NAME �+r ! Ma CARE OF ADDRESS INFORMATION a be P-1 mtkoid &4 4pr- MAILINGorSTREETADDRESS , ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION O LOCAL-AGENCY ❑ FEDERAL-AGENCY 1 (� L CI ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME EA �� STA ZIP CODE _ D / PH NE NITH.—��YOOE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)S S NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. ❑ II. 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY a JURISDICTION R AGENCY N FACILITY ID a a of TANKS at SITE 10101 A 0012- 1 10 C' 10 CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE a WITH AREA CODE i�g`LLM Z� PERMIT NUMBER PERMIT APPROVAL DATj"� PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT Yp�,j SUPERVISODE BUSINESS PIAN FILED DATE FILED XdYES NO CHECKa PERMIT AMOUNT SURCHARGFEE CODE RECEIPTa 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 fINFORMATION ONLY. �FpORMA(3-2-IM) N-81 O I 4w, DATA PROCESSING COPY