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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': ( f UNDERGROUND STORAGE TANK PROGRAM Vo _ s SITFMFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION °< o J- COMPLETE THIS FORM FOR EACH FACILITY/SITE `^A�roa��r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ®7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE W 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) A 00 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Sc,r� da COu.v ADDRESS 1 NEAREST CROSS STREET ✓gPbindd¢ D PAWNEASNIP D STATE.AGENCY l! fr s 1 f ❑ gRPOMTNN ❑ LOA AGF* ❑ F OEMI.AG NC O CAat ❑ INDNIOUAE Ok COUNTY AGENCY CITY IF STATE ZIP C DE SITE PHONE N,WITH AREA CODE ask CA s20c7> -75f - V�Z3 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax 4INDIAN EPA ID N ❑ of TANICs 1 GAS STATION ❑ 3FARM �6OTHER TRUST LANDS dT ❑ NON'S ATTHISSITE� 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 NIGHTS: NAME(LAST,FIRST) PHONE ng AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE "I<WOLA jNj U N t NOCl-n! II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATIOR Sam Joa u/,. Cou, -f ac GNB' MAILING or STREET ADDRESS I"Box to indicate ❑ PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY { //� O D INDIVIDUAL COUNTY-AGENCY CITY NAME STATE ZIP CO E PHONE N,VrTH AREA CODE de k 20 2oa - Ye-141 2-3 III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) ' CARE OF DDRESS INFORMATt ,2Nc' /)/sfn�fA- �rl�uN�ram� sso Z/c. MAILING or STREET Ann FSR R T— ✓Box to indicate D PARTNERSHIP D STATE-AGENCY O CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY IO D INDIVIDUAL COUNTY-AGENCY CITY NAME / / STgTi � ZIP CODE PHONE N.WITH AREA COD`/�� ${a(X�N �`nIf/� 2 8 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ II. ❑ III. 0 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* JURISDICTION N AGENCY41 FACILITY ID R R of TANKS at SITE 3l 100 00 CURRENT LOCAL AGENCY FACILITY ID* APPROVED BY NAME PHONE*WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE JCOLECK# E CENSUS TRACT* SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: HIS FORM MUST BE ACCOMPANIED BY AT IEAS�(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CNANGE OF SITE INFORMATION ONLY. Ni A(3-2-BSI DATA PROCESSING COPY y�