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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A':OC UNDERGROUND STORAGE TANK PROGRAM n "fir 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 PERMANENjLV�CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE VV!!JJ I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Simon fe ENCY ADDRESS NEAREST CROSS STREET ✓&AbiMfale ❑ PARTNERSHIP ❑ STATFEDS AGENCY 309 S Tace�ne o ND�ND4ITG' o LOCAL Cq� CITY NAME i p On STATE FE ZIP40533 3 6 19NE M,'H AREA CODE JIM TYPE OF BUSINE53. ❑ p STRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N If of TANK'Y RESERVATION or ❑ AT THIS SITE F-11 GASSTATIGN 3 FARM ❑ 5 OTHER ITRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE NREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE Wes t5 t nit - f I NIGHTS. NAME(LAST,FIRr) PHON N WITN AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE We 'n�dn, 9 599•X3899 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S'2mG 2S r MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE 21P CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY Cl 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 ABOVB ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ uL❑ 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 E JURISDICTION R AGENCY N FACILITY IDM M of TANKS at SITE a o / CURRENT LOCAL AG;CENSUSTMCtT# OEUPLANFILED PHONE N WITH AREA CODE w PERMIT NUMBERPROVAL DATET EXPIRATION DATE LOCATION CODE SUPERVISOR- ILED DA�1TE FILED YES ❑ NO p[' 5- 9 0 CHECK I SURCHARGE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIOJON \ ORM (3-2-00)