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� v _ STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM - o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : o COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ i EW PERMIT F-13 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOS N ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �7. I. FACILITY/SITE INFORMATION &ADDRESS- (MU TBE COMPLETED) -a' W FACILITY;E NAME CARE OF ADDRESS INFORMATION S N JOAQ,uIN ADDRESS NEAREST CROSS STREET ✓Bawaaale ❑ P ❑ STATE-AGENIX DW, �7 � 2n o INUMDUAL AGCOWWPON �QLY o .a°a� j CITY NAME STATE ZIP CODE SITE PHONE p.WITH AREA CODE CA TYPE OF BUSINESS: 2 DISTRBUTOR 4 SSOR ✓Boz 6INDIAN EPA ID p RESERVATION or p of HIS SITE / ❑ 1 GASSTATION ❑ 3FARM 5OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS._NWE(LAST,FIRST) PHONE p WITH AREA CODE DAYS. NAME(LAST,FIR PHONE If WITH AREA CODE n/4 1A, G -ffoo SMrre 66F S3C? NIGHTS: NAME(L,40T,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE N II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME c /7 u CARE OF ADDRESS INFORMATION Jl�/� �A 4cG�✓ LSC/ IV MAILING or STREET ADDRESS ✓Box to mclicate ❑ PARTNERSHIP ❑ STATE-AGENCY !_/� / ❑ CORPORATION 11LOCAL-AGENCY 11FEDERAL-AGENCYZ A� �i✓ « 13INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP OBo PHONE k,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE(COMPLETED) NAME - � � 4,��t4fee45.1 / CARE OF ADDRESS INFORMATION MAILING or STREET AOj�RE /// p cq,��W`�/IgN/_� ✓Box to indicale ❑ PARTNERSHIP ❑ STATE-AGENCY El CORPORATION 1:1 LOCAL-AGENCY LIFEDERAL-AGENCY 7 V {'_ ✓�✓ ��L FY 11 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME � / STATE ZIP COD�_� PHONE pWITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD REUSED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ If. ❑ 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 p JURISDICTION N AGENCY# FACILITY ID# #of TANKS at SITE [fflDO ? 6 I 1 (900 �/ CURRENT LOCAL AGENCY FACILITY 10 S APPROVED BY NAME PHONE p WITH AREA CODE 5D PERMITNUMBEII PERMIT APPROVAL DATE PERMIT EXPIRATION DATE E ODE CENSUSTRACT� SUPERVISO -DISTRICT CODE BUSINESS PLAN❑FILED ❑ DATE FILED ^e`a 22 zo VES NO O PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTIf BY�� 1 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. ' 1 FORMA(3-288) DATA PROCESSING COPY