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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM 17 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , I COMPLETE THIS FORM FOR EACH FACILITY/SITE "1OPi�H MARK ONLY �W PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 ENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N FACILITTBITE NAM CARE OF ADDRESS INFORMATION (,Ar 6PW(� 0 — /l/�iVf ADDRESS NEAREST CROSS STREET ✓Boren MUT110 C PAATL AGENCY STATE FEDERAGENCY AGEN 3 I I I ❑ WflPOMTION ❑ COUNTY AGENCY FEDERAL AGENCY Cl INpNIOUAL ❑ COUNT!-AGENCY CIN NAME j STATCA ZIP E � SITE PHONik�ITH AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N �!/Np/A X Of TANK'N 5 ❑ 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUSTY Too Or F-1 AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREEA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) P ONE k WITH AREA CODE NIGHTS. NAM�LAS ) PHONE N WITH AREA CODE SA- aq- 7 01w`r II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION C A-u o F mdS 1Z1 MAILING or STREET ADDRESS ✓Box lo'mdicale C PARTNERSHIP STATE-AGENCY I1 0 L+ ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ll I J C INDIVIDUAL ❑ COUNTYAGENCY /AA/p'I� STATE 217 CODE—� ^ PHONE u.WIT =EA CODE CITY NAME S MJ /}W_vrc 9 5 /{ III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS & 5 ✓B°x lo,Yd,cale C PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION C LOCALAGENCYC FEDERALAGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY STATE ZIP CODE PHONE N,WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 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 X JURISDICTION X AGENCY X FACILITY IDX X o1 TANKS at SITE ©7yU = I d o i CURRENT LOCAL AGENCY FACILITY 1 N APPROVED BY NAME PHONE N WITH AREA CODE 723 PERMIT NUMBER PERMIT APFROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACT SUPERVIS R-DISTRI CODE BUSINESS PLAN FILED DATE FILED �j ; XC) � YES � NO CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N B��4ONLY THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S),UN�S THIS IS A CHANGE OF SITE INFORMA FORM A(3-2-88) • DATA PROCESSING COPY