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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM " Z _ �, � SITE /� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to«,._ . I /! COMPLETE THIS FORM FOR EACH FACILITY/SITE 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN Y CLOSED SITE MARK ONLY ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ju A I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 00 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS „-,/ N�!E T CROSS STREET ✓ I0x6mw ❑ wilEf6HIP ❑ STATE-AGENCY CGMWGN 4❑ F;7)EINL AGEN INDAI ❑ m6m LY CITY NA l_ STATE Z PDQ-E� � � I��O N.WITH AREA��I CA U/ lr S 9 4 TYPE O BUSINESS: 2 DISTRIBUTOR 4 P CESSOR '/Box if INDIAN EPA ID x If of TANK' t /'� ❑ RESERVATION or p y ,, y ATTHIS SITE DU ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ e� o 0I SI Z 6 L EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYJ NAME(LAST.FIRST) PHONE 4 WITH AREA CODE DAV NAME(I-AST,FIRST) P NEM WITH AREA CODE VA NIGHTS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE NIGHT . NAME(LAST.FIRST) Lt E N WITH AREA CODE J� II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) N CARE OF ADDRESS INFORMATION �D MAIL( or STREET A KESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ,p O Cl INDIVIDUAL Cl COU TY- AGENCY CITY E STATE ZIP CODE PHONE . ITH ARE CODE 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or ST ET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If.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. 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# JURISDICTION M AGENCY N FACILITY ID fl IY of TANKS at SITE 3 1 06 1 [ k 1,- Ob 10 12 CURRENT LOCAL AGENCY FACILITY R D BY AME PHONE 0 WITH AREA CODE _? 71 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E% (RATION DATE LOCATION CODE FERMI AMOUNT SURC ARGR AMOUNT CODE FEE CODE SINESS%SN FILED ❑ D� I 7 L THIS FORM MUST BE ACCOMPANIED BY AT LEAST11)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-6B) `�/ DATA PROCESSING COPY �`