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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM e SFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑o CHANGE OF INFORMATION 7 PF RMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME �) CARE OF ADDRESS INFORMATION G 1- ADDRESS NEAREST CROSS STREET ✓ n0ub ❑ PARTNERSHIP 0 STATE-AEPICY ❑ INMID k El `I��Rm AGNa AGM ❑ FEOBw Nx CITY NAME STATE ZIP CODE §JTE PHONE N.WITH AREA CODE CA aao R q31-,2191) TYPE OF BUSINESS-. ❑ y DI IBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N N of TANKN ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME BAST,FIRST) PHONE N WITH AREA CODE G bei ao4 131 -a O NIGHTS'. NAME(I—AST,FIRST)�� p PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION � h ' Trus MAILIND,TTREET ADDRESS A ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDE A -AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY Ci( CITY NAME c �"Uh. STATE 21P CODE ` Ro3E N WITH REA—Ca 9 7 o III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) J NAME �'`�� /�, ,{�/ CARE OF ADDRESS INFORMATION !f wi��c' WfJ.J ✓ N.V LW MAILING o,STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 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 ADDBM$$SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ IL ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION E AGENCY R FACILITY R of TANKS at SITE " [HE ) ('�7 0 0 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BT NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA1 CODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED a 3. 013 YES NO CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN ST: // 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 ONL5 FORM A() �c� uj 1 _