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f STATE OF CALIFORNIA FORM `A': WATER RESOURCES CONTROL BOARD SITEUNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FOR"FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ONE ITEM S RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑2 INTERIM PERMIT 4 ❑ AMENDED PERMIT r-16 TEMPORARY SITE CLOSURE 7 PERMANENTLY CLOSED SITE F-► I. FACILITY/SITE INFORMATION &ADDRESS - d N FAC,77Y=,; (MUST BE COMPLETED) i M (xaYIN 00frpPM47,1 .J C RE OF ADDRESS INFORMATIO �M ADDRESSJ .I. 1-" r'- 1N 2&2q V. /,N NEAREST CROSSSTREET / oro ST CITY NAME / I pgT 0 L ElFRIP&BX,y I� ❑ NGMDWI ElO MIY.AGBVCY ❑ ROERILAGEHCY/ J STATE ZIP CA ODE SITE PHONE p,WJH AREA CODE TYPE OF BUSINESS: ❑2 DISTRIBUTOfl ❑4 PROCESSOfl ✓Box if INDIAN EPA Ir�^- _�-/a Z•Z_ ❑ 1 GAS STATION ❑3 FARM 5 OTHER RESERVATION or - TRUSTLANDS ElG N of TANK's EMERGENCY CONTACT PERSON(PRIMARY) Ar rNIS SITE Z j DAYS: NAME(usr.FIRST) EMERGENCY CONTACT PERSON(SECONDARY) •q PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) c- L Q4_ — g•� PHONE p WITH AREA CODE NIGHTS: NA (LAST,FIRST) l(PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) IN 2 3-/$ZZ PHONE#WITH AREA CODE II. PROPER OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME, 74 C �1.. CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ CORPORATION ❑ LOCAL AGENCY ❑ STATE-AGENCY CITY NA [j PARTNERSHIP ME ❑ INDIVIDUAL ❑ COUNTY-AGENCY 11 FEDERAL-AGENCY STATE ZIPCODE PHONE#,WITHAREACODE 111. TANK OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) NAME c CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 11 PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,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. 11. ❑ 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 R AGENCY# FACILITY ID R If of TANKS at SITE DUBt 2Z 00 D CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME MZ8 PHONE k WITH AREA CODE c L4 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE N LOr^�^••-ODE CENSUS TRIA',I/T,# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FEED C� � 1 23. p�J YES [-] NO 1:1 CHECK. PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 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 A(S-2-B8) J(\ a� DATA PROCESSING COPY �/