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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD `A W. FORM `A': UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 71— COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE x ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE s I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓9�Ab Ygkak D PARTNERSHIP D STATE AGENCY ~` - PL l O CORPORATION D LOCAL-AGEND D FEDERAL-AGENCY 'l D IND DUAL D COUNTY-AGENCY CITY NAME �n STATE ZI�COj1ETE PHQNEA.W AREA CODE � TYPE OF BUSINESS: F-] 2 DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID # RESERVATION or #of TANK's ❑ t GAS STATION [:]3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME J CARE OF ADDRESS INFORMATION C11-1 QF GFOC-e-M MAILING or STREET ADDRESS ✓Boa to ioaicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY E_ I 31 (� D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE STcc r- ,J GA 5202 q L4 4 - 2 2_ III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME ��-� CARE OF ADDRESS INFORMATION SA-7'�1pp,,-u VV MAILING or STREET ADDRESS ✓Boa to iooicate D PARTNERSHIP D'STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE I,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. ❑ 111. ❑ 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 M JURISDICTION R AGENCY R FACILITY ID R Al of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE W 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIOtICODE CENSUS TMA—,M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO ❑ DATE FIL O �� CHECK# PERMIT AMOUNT SURCHARGEAMOUNTFEE CODE RECEIPT 3 BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST,(')OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM AA\(3-2- *mw^88)^ ` ` J / DATA PROCESSING COPY— '� - ��1��/V//