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STATE OF CALIFORNIA ' WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMo SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® : o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT R, CHANGE OF INFORMATION ❑ 7 PERMANENT OSED SITE I"'a ONE ITEM ❑Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) OD W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION (� A-G ' ADDRESS b F..&)o d d- NEAREST CROSS BTREET ✓BORPOIr TIO ❑ LOX AGENCY ❑ STAFEDEMLGENCY aESS YA.`/ ❑ COWN.tON Cl RARTN ENCY ❑ FEDTE AGENCNCYY I 0 INDIVIDUAL ❑ COUNTY- AGENCY CITY NAMESTATE ZIP CODE SITE PHONE It.WITH AREA CODE CA TYPE OF BUSINESS ❑ p TRIBUTOR f—] 4 PROCESSOR ✓Boz If INDIAN EPA ID a RESERVATION or ^ ,^ - A� N of TANK'S ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS 1:1 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 It WITH AREA CODE 07 a Y% is ovu le a09 ??- NIG TS: NAME(FAST FIRS PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE &Lr le oR a — a 5 II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADORERS INFORMATION TY`p v%C i 4 k a K MAILIII STREET ADDRESS -/Box to irldicale ❑ PARTNERSHIP ElSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME ,1 STATE ZIP CODE r PHONE A,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box la intlioate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE p.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: L ❑ if. KeK 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 R JURISDICTION N �AGENN FACILITY ID M N of TANKS at SITE m M = ya l 101 oa03 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE YhIgc►^n�a3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [CHECK CATION CODE CENSUS TRACT k SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO 3 / ) PERMIT AMOUNT SURCHARGEAM� FEE CODE RECEIPTX BY W/ 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(3-243) —" DATA PROCESSING COPY