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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITEC� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 'pi5 CHANGE OF INFORMATION ❑ 7 PEO TLY CLOSED SITE r ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 00 N FACILITY/SITE NAMA AR TgA_c-rai 14& CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bm bindicate Cl PARTNERSHIP 0 STATE AGENCY �/, Q I I Cl CORPORATION Cl LOCAL-AGENCY 0 FEDERAL N A U 0 INDMDUAL Cl COUNT AGENCY CITY NAME STATE ZIP CODE 6 SITE PHON p,WWITH AR)=A TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box If INDIAN EPA ID a S ^I�V/� TAN ��s —/J} RESERVATION or AOI HISSI ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME ST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE a ITH AREA CODE SIAN(e 209— nlGln I-bHo _ ON3 NIGHTS: NAME(LAST.F T) I PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESP %/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ( O N 6U 0CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE5PHONE a,WITH AREA CODE GPr 9 0626 1- -07 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION AS MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS 1-11 CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ U. 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION If AGENCY W FACILITY ID k N o1 TANKS at SITE aE 10101110 DO 10 CURRENT LOCAL AGENCY FAICV.ITY ID 0 APPROVED BY NAME PHONE N WITH AREA CODE NT 1 "1 PERMIT NUMBED PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTM SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED NO ❑ DATEF / CHECKN PERMIT AM NT SURCHARGE AMOUNT FEE CODE RECEIPTF S` , A / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE(INNFFO,RRMMAAATTIJIO/N ONLY. FORM A(3-2-88) �' DATA PROCESSING COPY "'�