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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r.: FORM 'A': 1 . ` UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o C/ COMPLETE THIS FORM FOR EACH FA ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT VICHANGE OF INFORMATION7 NTLV CLOSED SITE h ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME _ , 1 CARE OF ADDRESS INFORMATION r S, /✓/Gi �G u�j ADDRESS r/ NEAREST CROS�SfST�R�EEZ ✓BrAw mole CerARTNERSHIP 0 STATE AGENCY 13 0 IND�DUALORATIDN 0 COUNTY AGENCY El LOCAL AGENCY [IFEDEAALAGENCY CITU NAME 5 _ / STATE 21P C00 ` SITE PHONE p,WITH AREA CODE TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 CESSOORR/��'��✓/BOX if INDIAN EPA ID # /Q b RESERVATION or ❑ XaI TANK'e ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS ME(LAST,FIRST) �_ PHONE N WITH AREA CODEDAYS AME(LAST,FIRST( PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS'. NAME(LA FIRST) PHONE N WITH AREA CODE G4 4 r� II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ' ��, , 4/�Li l CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS 0 ,r`=moi' ✓Dox to,,d,cale ARTNERSHIP 0 STATEAGENCY JS(�- Poe ❑ CORPORATION LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE# WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to iodicate C�y1CRTNERSHIP 0 STATE-AGENCY ❑ CORPORATION [❑�LOCAL-AGENCY 0 FEDERAL AGENCY INDIVIDUAL COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. v it. ❑ 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 k JURISDICTION M AGENCY k FACILITY ID 8 It of TANKS at SITE [k] 10 2- 49 .-rr lJ OO CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE M WITH AREA CODE wAa PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISO/ISTRIGT CODE BUSINESS PLAN FILED NO ❑ DAT FILED CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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. FORMA(3-2-88) DATA PROCESSING COPY 40