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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM p � " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 EW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 P NENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT El4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE CD I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITYISITE NAME CARE OF ADDRESS INFORMATION ADDRESS B 5. NEAREST CROSS STREET ✓9RGptina ❑ LOWAGNP ❑ FSTATE EERAL BICE WO ❑J CDSAWALN ❑ LOG4pG ❑ RLEMLAG NIX INBMWAI ❑ Qwm-AGBIGY CITY NAME ��/ STATE ZIP CODE SITE PHONE p.WITH AREA CODE �K i-/ Aye 9 TYPE OF BUSINESS: ❑2 DISTRIBUTOR / ESSDR '/Box if INDIAN EPA ID # 1 GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ T%(171('i ❑ ❑ TRUSTIANDS 'ATTNIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON E CONDARY) DAYS: NAME(LAST,FIRST) PHONEp WI H AREA CODE DAYS: NAME(LAT,FIRST) PHONE N WITH AREA DO�, m P�R�D — 9��-�s2es �a Q NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST, ST) PHONE N WITH AREA CODE 1,4x1¢. u II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION O(r� Owl MAILING or STREET ADDRESS ✓Box to indicate ElPARTNERSHIP ❑ STATE-AGENCY 1 0 , n/Q O 7 N/� 11IND V DUALION ❑ COUNTY AGENCY ❑ FEDERAL-AGENCY CITY NAME STATE ZIP CODE � p PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) 8 ` NAME CARE OF ADDRESS INFORMATION S/x�n.e a 5 MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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: L ❑ 11. 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY N FACILITY ID N N of TANKS at SITE ml = = I L) O / 161 / O 0U 101,31 CURRENT LOCAL AGENCY FACILITY ID APPROVED BY N§ / PHONE p WITH AREA CODE PERMIT NUMBER 5 fi PERMIT APPROVAL DATE W�PERMIT EXPIAATION DATE LOCATION CODE CENSUS TRACT N��D f7� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 49/ O YES NO El CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* 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 INFORMATION ONLY. . FORM A(3-2-88) �- DATA PROCESSING COPY +�