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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD hh' tM1F FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM F0 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I d FACILITY/SRE NAME CARE OF ADDRESS INFORMATION 13" a c L°e ADDRESS NEAREST CROSS$TREEf _✓ay amok ❑ PARTNERSHIP ❑ STATE AGENCY N K G'Co rvoRATiox ❑ touACExa O emwt aGENa co e/I LYL. w ❑ INomIDUAL ❑ coum ASBx;y CITY NAME STATE ZIP CODE SIT�E1 PHONE p,WITH AREA CODE S CA TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Box 4INDIAN EPA ID xIr p ❑ I GAS STATION ❑ 3 FARM OTHER TRUSTVLANDS ATION Dr ❑ /I� dw C_ AT THIS SI AT THIS SITE RESEEMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE h ao4 4� G- ao NIGHTS: N (IAST,FIRST) PH NENWITHAREA CODE NIGHTS: NAME(LASTFIRST) PHONE N WITH AREA CODE So yn� II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION N MAILING or STREET DRESS �gOx to ift..e ❑ PARTNERSHIP ElSTATE-AGENCY DP CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE _%-od4o c,fq -, Ci3 Caoq �f(oG-�aoz III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION TgM ,e 6 S o er Leh MAILING or STREET ADDRESS ✓Box to inftate ❑ PARTNERSHIP 0 STATE-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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY R FACILITY IDN N of TANKS at SITE © D I SF 00 CURRENT LOCAL AGENCY FACILITY 10 N APPRO ED Y NAME PHONE Al WITH AREA CODE 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUP VISOR-DISTpI—II4 T CODE BUSINESS PUN FILED DATE FILED CIAD / 3 , 0 V Z O YES NO ❑ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ONLY. FORMA(3-2-58) � I, �-� DATA PROCESSING COPY