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STATE OF CALIFORNIA- WATER RESOURCES CONTROL wOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r. COMPLETE THIS FORM FOR EACH FACILITY/SITE �'��•oa"" MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Ga rrt ADDRESS C NEAREST CROSS STREET ✓&abMrwK 0 PMTNMP 0 STATE KOO 8633 `. 0 OOWOMTDN 0 LOCAL#4TD 0 FEDtWLAGENCY' ❑ r0WXAI 0 CWNTI'-AGENGY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE 5 CA gMZx1 - ,� -3r 5 3 TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box I INDIAN EPA ID N t GAS STATION 3 FARM 5 OTHER RESERVATION or N of TANICN ❑ ❑ TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 01 f -1127^5563 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 2 wl�ti}� 001, &klB MAILING or STREETADORE5.4 ✓Box to Ind.[. 0 PARTNERSHIP 0 STATE-AGENCY `O , 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE, ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BECOMPLETED) J NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to ln0icate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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. ❑ H. Yl 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 R AGENCY N FACILITY ID N k of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE _LE M E'3 PERMIT NUMBER PERMA APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDcig DATE FI D Q 3.�� j.ZO YES NO 11 IJP 0 v` CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: iL `\1 THIS FORM MUST BE ACCOMPANd![N Y AT LEAST(1)OR MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. CEJ ORM A(3-2-BB) Iv1 a\ 0j \� �� ' 1