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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �'" Sl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o 7Z COMPLETE THIS FORM FOR EACH FACILITY/SITE anx r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) cc w � FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W ADDRESS /' NE E TCROSS STREET ✓puvm Ngvak ❑ PAAfNEASIIP ❑ FATEAGENCY 33 ,55: N, QG�I flT> R d. a ouch O ccencBxr ❑ FnwuAcwc CITY NAME /LN Y\ STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA 5213 Cao431-1 7 TYPE OF BUSINESS ❑ p D TRIBUIOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a �1—�� ❑ I GAS STATION 3 FARM ❑ S OTHER TRUSTVATION LANDS of ❑ / �� NlLl_ It of TANK'e AT THIS SITE Q EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAV NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE e ahc ; ao4 3! — 0771 NIGHTS: NAME(LAST, IRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME �Y N, CARE OF ADDRESS INFORMATION v /JL MAILING or STREETADDRESS ✓Box to intlicale 0 PARTNERSHIP ❑ STATE-AGENCY 1 ❑ CORPORATION LOCAL-AGENCY O FEDERAL-AGENCY 16 1 U /{'L� • \ r ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME '�.N " _l..N/✓�--� STASE� ZIP CODE PHONE N.WITH AREA CODE CC Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME _ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS &IF Rax to intlicate El PARTNERSHIP 11STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 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. ❑ it. ❑ 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 M JURISDICTION M AGENCYIN FACILITY ID M M of TANKS at SITE 3 I I101 ol 61 a CURREN OCAL GENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT ON DE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA F1 ED g 3, cx 5 YES NO lale CHECK IN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: THIS FORY MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. IA(32 ) V�. DATA PROCESSING COPY A