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STATE OF CALIFORNUC' WATER RESOURCES CONTROL`tOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE A FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME 1 / � r l /y`[�l //�' CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ADDRESS l50 6 F� l-�w. 8ff MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7PE, RMA�1 ENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT [-]4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 63 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME 1 / � r l /y`[�l //�' CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ADDRESS l50 6 F� l-�w. 8ff NEAREST CROSS STREET ✓Bpv b' ❑ PAPTNEPSIIP ❑ SfRTEAGENCY o RM,>oN Cl COCA AfAM o ED UL.ADBG a ❑ CORPORATION ❑ LOCALAGENCY❑ FEDERAL -AGENCY DMDWL ❑ CWN1V-AAENd CITY NAMEe STATE ZIP CODE S PHONE WITH AREA CODE jol -7 � -1 a W CA l/ -3 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ BOx if INDIAN EPA ID k N of T ❑ i GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or I TRUST LANDS ❑ BY: AT THIS SITE IS SI EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST. FIRST) PHONE N WITH AREA CODE 21 I—/ T Z — DAYS: NpMIE,(LAST, FIRST) U` PHONE a WITH AREA CODE NIGHTS: ME (LAST IRST) PHONE N WITH AREA CODE NA NIGHTS: NAME (LAST FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME s0_7-��s� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate 'Cl PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL AGENCY MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CITY NAME ❑ CORPORATION ❑ LOCALAGENCY❑ FEDERAL -AGENCY ZIP CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE N. WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ('palm e as CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate 'Cl PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL AGENCY CURRENT LOCAL AGENCYFACILITY CILITY 1 # ,/; , ❑ INDIVIDUAL ❑ 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. 11. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPUCANT'S NAME (PRINTED A, SIGNATURE) DATE LOCAL AGENCY USE ONLY ��CODU717 I �NT/YY ## JURISDICTION Al = AGENCY R FACILITY ID Al �'N1of TANKS at SITE � V o 16,011/d/ CURRENT LOCAL AGENCYFACILITY CILITY 1 # ,/; , APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE DE LCHECK# CENSUS TRACT N SUPERVISOR ISTIIU T CODE BUSINESS PLAN FILED YES NO DATE FILLED PERMIT AMOUNT SURCHARG OUMT FEE CODE RECEIPT N 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. \IjI\VII FORM A(3 -2 -BS) DATA PROCESSING COPY