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qeN qui+. '�f STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE r FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o P COMPLETE THIS FORM FOR EACH FACILI E MARK ONLY F-11 NEW PERMIT F-13 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS ` NEAREST CROSS STREET ❑ t ButedcamN ❑ LOCAL AGB✓LY ❑ FEDENL NSEtkY 6 /� ❑ 1HmADUa ❑ uumNCFxa CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE �SCa to rz CA 1� U9_dl&IP-Grin TYPE OF BUSINESS2 DISTRIBUTOR E 4 PN�SSOR ✓Box it INDIAN EPA 10 N _ M of TANK's ❑ / RESERVATION or ❑ AT THIS SITE �— ❑ 1 GAS STATION ❑ 3FARM LLJc"'°'OTHER TRUST LANDS EMERGENCY 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 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE SW �+-L� _55--1- 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION i�L.Q R 5 Ab _� MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME / T CARE OF ADDRESS INFORMATION �-rn2 G"GS ri h O d� c[-- MAILING or STREET ADDRESS Be.✓ toin0icate 0 PARTNERSHIP 0 STATE AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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. 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 M AGENCYIN FACILITY ID R N of TANKS at SITE 3 9 O O ,? 12 1 316, 1 0 0 CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE EPE:RMIT PERMITAPPROVALDATE PERMIT EXPIRATION DATE US TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED a 33a6 YES NO � 'y/jD AMOUNT SURCHARGE AMOUNT FEECODE RECEIPTN 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 FORM A(3-2-SB)