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S.� <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARDQ ' <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM �► :� 'tf "o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '' <br /> COMPLETE THIS FORM FOR EACH FAMITY/SITE Ire <br /> MARK ONLY ❑ I NEW PERMIT ❑ 7 RENEWAL PERMIT CHANGE OF INFORMATION ❑ T PERMANENT , ITEC <br /> ONE ITEM ❑ 2 INTERIM PERMIT ED / AMENDED PERMIT -❑ 6 TEMPORARY SITE CLOSURE 7 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITES NAME <br /> � J / CARE OF ADDRESS INFORMATIONAMORESS / ��''1T A✓ C{/� /! NEAREST CRO SS STREETNAfl <br /> ✓gubmol, ❑ Ffytp 13Afflwl. <br /> $fAfF <br /> ❑ GYNIMTON <br /> ❑ ❑ IOGI.WAIV ❑ FEDUk.I DO <br /> rONaw ❑ caNn,lr[Ix,T <br /> CITY NAME % - ` STATE 21P CODE SITE PHONE v.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS ❑ 2 2 OLSTN&ITOR ❑ /PRO(FSSOR ✓Bov A INDIAN EPA ID v <br /> ❑ I W STATIONffill-A�AM ❑S OTHER flESERVATION a ❑ { <br /> I M TANKY /71 <br /> TRUSTLMOS AT TRIS SITE `// <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE v WITH AREA COME DAYS: NAME(LAST,FIRST) PHONE v WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE Y WITH MFA CODE NIGHTS NAME(LAST.FIRST) PHONE A WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING a STREET ADDRESS \ ✓8w w MItl . ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME \ STATE ZIP CODE PHONE S.WITH AREA CODE <br /> III. TANK OWNER INFORMATION St ADDRESS — (MUST BE COMPLETED) <br /> NAME \ CME OF ADDRESS INFORMATION <br /> MAILING a STREET ADDRESS 1 ✓8a w wl o ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1 Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> Cl TV NAME \ STATE ZIP CODE PHONE 1.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD'BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING. L IL ❑ IIL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) 'I DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY F JURISDICTION E AGENCY F FACILITY ID B F of TANKS At SITE <br /> = L221 C '-f 10 17 a G G <br /> CURRENT LOCAL AOE CT FACILITY 10 F APPROVED BY NAM! PHONE I WITH AREA CODE <br /> \ / <br /> `\ PERMR'MJMIEII PERMIT APPROVAL DATE PERMIT EIVIRATION DATE <br /> 1 <br /> vLOCATION COD! CERINS TRACT F SUMAINAOR4HpTRICT COO! BUSINlON P414 FILED DAT!FILED <br /> n( <br /> YES IID <br /> CHECK 0 L/ RRMIT AMOUNT SURCH11R0�U� FEE COD! ❑RECEIR ❑ / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEI— ')On MORE TANK PERMIT FORM 'B'APPLICATION(S).UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> \J <br /> FORM A(]-2-M) { <br />