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STATE OF CALIFORNIV WATER RESOURCES CONTROLBOARD Nu FORM `A': / \'^ UNDERGROUND STORAGE TANK PROGRAM =�" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N ��111 J+. FACILITY/SITE NAME KN L - /� 1 S CAflE OF ADDRESS INFORMATION 0 111 ADDRESSNEA REST CROSS REET ✓9m to intlmete Cl PARTNERSHIP ElSTATE-AGENCY G W R 9 M� 9.. u g- o Inovloo rlGe O COUNTY AGENa ❑ mERn�Acen CITY NAME STATE ZIP gppE SITE PHONE p WITH AREA CODE TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR Box it INDIAN EPA ID If ❑ SE I GAS STATION E] 3 FARM ❑ 5OTHEA TRUSTVLVATION ANDSo 1:1 #of TANK'# AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. N ME 1U,TT) � u�_ i�E�ITH AREA CODE OAVS'. NAME(LAS Eq) PHONE q WITH ARF NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMEZR. CARE OF ADDRESS INFORMATION �157. MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY 1 O Ioy ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME GTATE ,� ZIP CODE 9PHONE p,W`T �70 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) Y/ NAME A' CARE OF ADDRESS INFORMATION J W�t (A/J l MAILING or STREET ADDRESS I/Be.lo'odicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.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. ❑ II. 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# It of TANKS at SITE ® = = I ori I 11 6 = 8 1 a I -o ° 3 CURRENT LOCAL AGENCY FA LI ID# i�.(,(� APPROVED BV NAME PHONE#WITH AREA CODE ��Ni�' VYU PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO CODE CENSUS TRACT# SUPERVISOR-DISTRICT ODE BUSINESY SN FILED NO ❑ DATE FILED Q Z `DDj/ Z CHECK# PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPTp BY. THIS FORM MUST BE ACCOMPANIED BY AT LEASOR MORE TANK PERMIT FORM 'B'APPLICATION(S), ,ESS THIS IS A CHANGE OF SITE INFORMATION ON 1 I FORM A(3-2-88) . \v11V1 ,�,�p f + ' 1 L/ DATA PROCESSING COPY