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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD W FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION < 10 -1 COMPLETE THIS FORM FOR EACH F ILITY/SITE FMARK 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 CLOSURELil N I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) � FACILITY/SITE NAME CARE OF ADDRESS INFORMATION vw�(rP Sale ADDRESS N EST CROSS STREET beCiuY ❑ PARRIERSNP ❑ STATE MEND CgRNRATIM ❑ LOCAL-AGENCY ❑ PE➢RW AGENCY Z a Weil NDMoMU& ❑ CDUMAGENCY CITY NAME ��, _ / i w / STATE ZI COD SITE PHONE#, ITH REA CODE TYPEOFBUSINESS: ❑ 2 DISIAIBUT/�00RR/Ar-/ /V SSSSOORR/V✓BOzrf INDIAN EPA ID # /� FMTANK'� yo RESERVATION or ❑ 1 GAS STATION ❑ 3FARM 5OTHER TRUSTLANDS ❑ AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: AME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: N E(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST PHONE HONE 9 WWII AREA CODE NIGHTS: NAME(US R 1 PHONE#WIITTTHH AREA CODE II. PROPERTY OWNER INFORMATION \lf^J&,✓ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESSto indicate 13 PARTNERSHIP 1:1 STATE-AGENCY ORPORATION 11LOCAL-AGENCYD FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE Ar,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ,.//� CARE OF ADDRESS INFORMATION Ite MAILING or STREET ADD 0 iy uw/7/ tointlioate ❑ PARTNERSHIP ❑ STATE-AGENCY �O( o CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME II a STATE ZIP COPNONEiITM AREADE IV. LEGAL NOTIFICATIO AND BILLING ADDRESS CHECK ONE(N)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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE 1610 U3 CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE STS' 3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L OCATIONODE CENSUS TRACT N BUPERVICCODE BUSINES1P N FILED DATE� ` SFNG ❑ PERMIT AMOUNT SURCHARGE AMOUNT i FEE COD! RECEIPT# BY: ofd THIS FORM MUST BE ACCOMPANIED BY AT LEAST Ill OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS TH15A A CHANGE OF SITE INFORMATION ONLY. FORM A(3-Z RR) 9 IATA PROCESSING COPY l/ '/