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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 'E FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o Z SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 015 CHANGE O:INFORMATION ❑ 7 PER CLOSED SITEONE ITEM ❑Z INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORAE CLOSURE 53 W )_^ I.FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) F+ FACILITYISITE NAMES VQGLt// R CARE OF ADDRESS INFORMATION e ADDRESS }— NEAREST CROSS STREET ✓GeibiiRWe ❑ PAIRNERWIP ❑ STATE4610 / �beF �ex O 'mfrfr TION O `Cq AGBILY 00 FEOBUI.AGDO CITY NAME NDII STATE ZIP CODE SITE PHONE N.WITH AREA CODE O G CA d0 �+ TYPE OF BUSINESS: ❑p pISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM k'5 OTHER TRUSTYLANDS ATION o' ❑ A '� #of TANMF AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) L' PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE a oc" ✓ (--2 1,#) NIGHTS: AME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE S _A- II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Ra m an ve s !Ut C°a� , MAILING or ET ADDRESS /f �a ✓ ox toinEic'" ❑ PARTNERSHIP D STATE-AGENCY S, ce, p I J�N CORPORATION ❑ LOUNTY-AAGENCY ❑ FEDERAL-AGENCY C. INDIVIDUAL 11 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �' S u 61 MAILING or STREET ADDRESS ✓Boxto indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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 IS.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COOUNTYY# JURISDICTION R AGENCY B FACILITY ID R If of TANKS at SITE 00 CURRENT LOCAL AGENCY FACILITYAPPROVED BYONAME PHONE N WITH AREA OCODE 0 yn PERMIT HARRIER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDDATE FILED 3 , o1 14 YES NO CHECKx PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPTS BY: `1 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. FORMA(3-2-B8) - / DATA PROCESSING COPY .,F.�