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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ex•� ,E FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C:OSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ fi TEMPORARY SITE CLOSURE 53 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION r02Nr6C(O/l ADDRESS NEARES CROSSSTREET ✓Gov b nocia, 0 PANTNEASHIP 0 STATE-AGENCY cc 0 COPORATofl 0 LOGENLY 0 LAGFrE1014AGENGY 41 A ❑ mwfoU 0 COIMIYJ,OENC/ CITY NAMESTATE ZIP CODE SITE PHONE N.WITH AREA CODE xk C' CA 932.3 -207-W2 -OS TYPE OF BUSINESS: ❑2 DISTRIBUTOR' ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N RESERVATION or •of TANMN ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LAND$ ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(IAST,FIRST) PHONE N WITH AREA CODE me(11-N 7- - �2 i1�Z. O /u`' 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 MAILING or STREET ADDRE ✓Box to indicale D PARTNERSHIP 0 STATE-AGENCY ! / revr>, /) ❑ CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY G _ Frio..A"1n l Imo[° D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE T ZIP CODE PHONE N,WITH AREA CODE f, �' (2 95231 z z-6 2— Ill. 111. TANK OWNER INFORMATIO14& ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 0 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 OWN 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 APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY E FACILITY ID R E of TANKS BI SITE ul F= = I I I I I L CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE �BE'NC3 I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA. FILE- 2 D YES NO /90_T CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: �D e/-T THIS FORM MUST BE ACCOWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \ FORMA(3-2-SS) aii�