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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM'A': UNDERGROUND STORAGE TANK PROGRAM SITE A- FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER LOSEDSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (,6-3'1 1 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME el A pts CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS (/{�-'A-F-I• (^ '( ( r /�M `L'I L I` V 7C.x ADDRESS 2 L�/� / Ali OSSff)f NEAREST CROSS STREET ✓Babndcoe ❑ PAnEMIP ❑ STATEAGENLY ❑ WBPWDON 0 LOCAL-AGDO 0 FEDERILAGDO STATE V PHONE p, WITH AREA CODE 0 INDMWAL ❑ COONIYAGENLY CITY NAMESTATC �dr CENSUS TRACT N CODE SITE PHONE X. WITH AREA CODE DATE FILED 6�/�i� � n ZIP A AMOUNT U TYPE OF BUSINESS. ❑ 2,911 ❑ 4 PROCESSOfl ✓Box i( INDIAN EPA ID N # of TANKS ❑ 1 GAS STATION 3 FARM El OTHER SERV REATION or TRUST LANDS ❑ AT THIS SITE r EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS. NAME (LAST, F{R PHONE # WITH AREA CODE DAYS: NAME (LAST. FIRST) PHONE # WITH AREA CODE TH NIGHTS: NAME (USS`TJI, FIRST) PHONE N WITH AREA CODE NIGHTS. NAME (LAST. FIRST) PHONE # WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME / / /V •V' CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS (/{�-'A-F-I• (^ '( ( r /�M `L'I L I` V 7C.x �% � �(..�� ✓Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITU NAMEW A "� STATE ZIP COD 1 PHONE p, WITH AREA CODE L'g V ZIP CODE PHONE N. WITH AREA CODE LOCATION CODE CENSUS TRACT N SUPERVISOR -DISTRICT CODE �A Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION -V-", FACILITY ID # R of TANKS at SITE O O 10 1 MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP 13 STATE -AGENCY APPROVED BY NAME PHONE R WITH AREA CODE ❑ 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: 1. IK 11. ❑ 111. ❑ 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 N JURISDICTION N AGENCY # FACILITY ID # R of TANKS at SITE O O 10 1 CURRENT LOCAL AOENCxYS FA ILITY ID,M l/••f/ APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR -DISTRICT CODE �A BUSINESS PLAN FILED YES NO DATE FILED 6�/�i� CHECK PERMIT AMOUNT'SURCHARGE AMOUNT FEE CODE RECEIPT# BY�� 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 ONL I FORM A (3 -2 -SB) DATA PROCESSING COPY 1"a' O7 N cc