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or r. STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A• UNDERGROUND STORAGE TANK PROGRAM A o SITE ZFACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONo COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY TE IJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE � l/ I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) F SITE NAM CARE OFA RESS INFORMATION IE ADDR ♦ NEAR CROSS ✓Boem i-0iale ❑ PAATNE(bHIP ❑ STATE AGENCY ❑ UATION ❑ LOCAL AGENCY ❑ FEDERALAGENCY N►/FiL/l. NDMDUAL ❑ COUNTY AGENCY CITY AME STATE ZIP CODS SITE P ON�WITH A2REA�DE Y3, CA S TYPE OF BUSINESS- 2 STRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID it _ x of TANK'S RESERVATION or ,( ❑ I GAS STATION 3 FARM ❑ 5 OTHER I TRUST LANDS ❑ L,/ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) S: N�A (AST,F RST 0� HONE N WITH AREA C0 DAYS: NA (LAST,FIRST) PH�11 FIp yJITH AREA CODE 72 _ NIGHTS NAM7EL(LAST FIRST) PHON TH AREA 1111 NIGHTS G:[JNAA�(LAST FIRST) PHONE�✓[`W�1ITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMEf� Y • / A, CARE OF_WpRESS INFORMATION MglLL11(J�'q(J'�'STj3EEE ADDR S vl,�(Y,J„`✓ Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY (/,,,JJJ]�oVO ❑ CORPORATION ❑ LOCAL-AGENCY ❑ EDERAL-AGENCY Ace ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME ST4JE- ZIPtOj$`� PHONE#,WITH AREA,CODE 24 III. TANK &NER INFORMATION &ADDRESS — (MUST BE COMPLETED) JJ(( NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY Cl INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#.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. ❑ Ill. ❑ 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 k AGENCY M FACILITY ID N N of TANKS at SITE ® I 3 aI ov o CURRENT LOCAL AGENCY FACT Y IDN APPROVED BV NA Ellk PHONE M WITH AREA CODE Sco TT u PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E% (RATION DATE LOCA ION CODE CEN 8TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAIN FILED DATA f GG ? ,21-2— 3 C}iN/~ YES NO CHEN 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. ///'''�� RMA 13-2-88) 14W DATA PROCESSING COPY �