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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A'N UNDERGROUND STORAGE TANK PROGRAM =" o SITE /►_ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m 10 COMPLETE THIS FORM FOR EACH FALITY/SITE a^ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENW CLOSED SITE F'+ ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �j3 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME ^rh CARE OF ADDRESS INFORMATION NVv` ADDRESS , NEAREST CROSS STREET ❑ RMIEFIRIIP ❑ STAEAGECf �gM8� OAENElRpuaGn/0 r! Q 6ezclee ❑ uODUnGENCY CITY NAME STATE ZIP ODE SITE PHONE x,WITH AREA CODE ltj5' m o CA J``�ZZU U!L TYPE 9596SINESS: ❑ 2 TRIBUfOR ❑4 PROCESSOR ✓Bax if INDIAN EPA ID x 1 GAS STATION TRUST LANDS ElATTHIS SITE 3 FARM ❑ BOTHER RESERVATION or #W TANK# / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(IAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Ull d� NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE x WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREETADDRESS ✓Dox to indicate 13PARTNERSHIP ❑ STATE-AGENCY 0 4 L Lim / CORPORATION 1:1 LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CIN NAME STATE ZIP CODE7 PHONE p,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Sox to md,cate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE x.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. [Pf if. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY# FACILITY IID R N of TANKS N SITE 101014( 1 / -7 V J��y 101010111 CURRENT LOCALIIQENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE 70 PERMIT NUMBER lyL` E !V—1/) PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO CO E CENSUS TRACT#2 SUPERVI OR-DISTRICT CODE BU81NE38 PIAN FILED DATE FILEo 6 Z3�l 3�Z0 YES NO 6 / CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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(3-2-581 >_i DATA PROCESSING COPY