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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD W FORM A: UNDERGROUND STORAGE TANK PROGRAM mo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 FERMAN NTLY CLOSE SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 7 I.FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILI TE NAME �A CARE OF ADDRESS INFORMATION - G„/Ui _ ADDRESS /M� //Jj) yA��/ ��'1 NEAREST CROSS STREET a I�3✓/LBwlokjxi P IP D STATE-AGDO �G/LJ `�`�rA-�CC.� GC/ V LI ING NIQUUN D CGUNIYAGENCI ❑ RGFA9L AGFNGY CITY NAME STATE 21P DE SI PHON ITH REA CODE ,J CA S� —q TYPE OF BUSINESS: 2 DISTRIBUTOR PROCESSOR '/Box if INDIAN EPA ID # S of TANK'/ ❑ 1 GAS STATION ❑3 FARM Fk OTHER TRUST LANDS RESERVATION m ❑ AT THIS SITE 21 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) ONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE r� P /G NIGHTS: NAM (LAST,FI ST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE P WITH AREA CODE II. PROPERTY OWNER INFORMATION 3 ADDRESS- (MUST BE COMPLETED) NACARE OF ADDRESS INFO ATION NAME 1"017 v MAILIN or SfREET ADDRESS ✓ ox to indicate D PARTNERSHIP D STATE-AGENCY CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NA , , STAJEE ZIP CODE �/ PHONE p.WITH AREA CODE qs- 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAM ` x, CARE OF ADDRESSINFOjl ATION MMUNiMSTRE ADDRoxto indicate D PARTNERSHIP D STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY INDIVIDUAL D COUNTY-AGENCY CITY NMS STATE ZIP�OD��/ P ONEp WITH AREA IV. LEGAL NOTIFICATION AND BILLING ADDRESS /(J 5 9 CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL [-] III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APP (CANTS NAME(PRINTED S SIGNATUgE) ' DATE A to LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY M FACILITY ID N N of TANKS H SITE ® 14 1 a I / 0O 1010 CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE N WITH AREA CODE R 6(eA PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATILCODICENSUSTRACTF SUPERVI80R-DISTRICT CODE BU81NE35 PLAN FILEDGATE FILE$VYESNO �(CHECKPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY:�� 1 l 41 THIS FORM MUST BE ACCOMPANIED BY AT LEAST 1 'MORE TANK PERMIT FORM'B'APPLICATION(S),UNI THIS IS A CHANGE OF SITE INFORMATION ONLY.( ' I FORM A(3-2-88) 1 DATA PROiSING COPY 2 LOCAL AGENCY COPY 3^'NLL COPY \