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�R/ oT-. STATE OF CALIFORNIA WATER RESOURCES CONTROkOARD r?E `"""' r`.A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM z 'I SITE /A FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION °< to (,/ COMPLETE THIS FORM FOR EACH FACILITY/SITE c""`==�� MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT Ej 5 CHANGE OF INFORMATION 7 P NENTLY CLOSED SITE 1'A' ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE CD 0 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) fV FACILITY/SITE NAME FSR Ri �A CARE OF ADDRESS INFORMATION ADDRESS `//) NEAREST CROSS STREET ✓Bwlontlisle D PAIRNEAGNIP D SEKW-AGEN Z D 1 `, 9 � ON✓PoMTIDN ❑ IOGAL-AGENCY ❑ FF➢FAAL-AGENCY ❑ IMNIDUPl ❑ CgMtt�AGENCf CIT'NAME 5 STATE ZIP COD,.-S-0 SITE PHONE^.'yljH K CODE_/ IV CA 5 Y '(7�0� TYPE OF BUSINESS: � 2 DISTRIBUTOR E3EPA ID M 4 PROCESSOR � Sa1 TANK'S RESERVATION or 1 GAS STATION 9 FARM 5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA OST,FI ST) PHONE p WITH AREA CODE DAYS'. A�NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: INANE(LAST,FIRST) PHONE p IT AREA CODE NIGHTS: NAME %T,FIRST) PHONE p WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME - / d CARE OF ADDRESS INFORMATION MAILING or STREET ODRESS � 1 /I`' I-. '` x,/ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY .1M` V 4W ✓'V ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY fw D INDIVIDUAL D COUNTY-AGENCY CITY NAME Ij'!ti; STATE ZIP E PHONEk,WITH ARFfyCODE III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box toindicate Cl PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY Cl FEDERAL-AGENCY O L ✓R o /T�( '(j{ !�7 4 D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMEST. / STATE ZIP CODE `� PHONE p,WITH AREA CO��// IV. LEGAL NOTIFICATION AND BILLING AD/DRESS CHECK ONE I7)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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION If AGENCY M FACILITY ID N S of TANKS H SITE Ell] 1010 0 1 KI I ol d CURRENT LOCAL A ENCY FACILITY I p ^ ey "MOVED BY NAME PHONE p WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# ODE CENSUS!T7RA1CT p SUPERVISOR- ISTRICT CODE BUSINESS PLAN FILED DATE FILE �j YES E] NO E] 1-11-it O PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BC� V / 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. / FORM W �� DATA PROCESSING COPY �..