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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD , , mr N&T FORM A: UNDERGROUND STORAGE TANK PROGRAM io SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ANLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION MANENTLY CLOSED SITE r~ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) -4 FACILITY/Sl AME CARE OF ADDRESSI ORMATI N .1S ADDRESS -Firm �� NEAREST ROSSS REET ZqlMOlA `Wmk ❑ PARTNERSHIP ❑ STATE AGENCY � -r, PTION ❑ LOCAL AGENCY ❑ FEDLAAIAGENGY CY CITY NAM STATE r ZTIP CODE OU SITE PHONE UW WITH AREA CODE rr� 2ec� CA 2 -2 - S TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID N N of TANK's ❑ I GAS STATION ❑ 3 FARM RESERVATION or ❑ /i AT THIS SITE 5 OTHER TRUST LANDS Imo, EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) PHONE p WITH AREA CODE DAYS: NAME((AST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) pICI .� 209-z-3Y_q15 < N NITS'. 34,11T,FIR T) PHONE NWITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE N WITH AREA CODE X17 Z 62 G( N 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME e�N C' CARE OFADDRESS NFORMATION c�N , o MAILING or ST EET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY C �+ INC13LOCAL-AGENCY ClFEDERAL-AGENCY 22, FCA r rn o; LJ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAM/n /�s4O STAT ZIP COODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMNGGJAi q AS �� ' L CARE OF ADDRESS INFORMATION `Nor STREET ADDRESS �LFn�/ MAILING -/Box to indicate ❑ PARTNERSHIP Cl STATEAGENCY O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.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. II. ❑ 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# JURISDICTION K AGENCY M FACILITY ID M #of TANKS at SITE - 06 .�z Fqs o- Id I l CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OAT F LED YES NO 1 2 G ff CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At Y: 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 FORM A(3-2-88) }� DATA PROCESSING COPY \L