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STATE OF CALIFORNIV WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION bra -Tl s ADDRESS /(//�/ ,,/ NEAREST CROSS STREET ✓CO RATIO 0 PARA ADEN 0 STATE FEDEM ENCY AGENCY I / / '7 E 5eaal? ❑ IfNDUIDU& O Lp T�FGEENNCf ❑ FEDEPAL-FGENd CITY NAME STATE ZIP,CpDE ITE PHONE.,WITH AREACODE marl fL'C�- CA X 36 a3 ! - TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i1 INDIAN EPA ID # ,�1 N of TANK'# ❑ 1 GAS STATION Q 3 FARM ❑ 5 OTHER TRUST RESERYLANDS ATION�r ❑ K14 - AT THIS SITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE S//,+ '51A 5�f1- NIGHTS: NAME(LAST,FIR T) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 15 s/& s 3/+ II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME 1A T CARE OF ADDRESS INFORMATION S!/I + MAILING or STREET ADDRESS ✓Box toindicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME 5�/} CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVI ADDRISB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. [:] Ill. ❑ 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 N JURISDICTION M AGENCY R FACILITY ID R R of TANKS At SITE " 39 = = Doha 9 eUo / CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE M fNL?7 77 PERMIT NUMBER FT.RC.AR.EA.OU. PERMLOCATION CODE CEN TRACT• UPERVISOR-D18T111CT CODE BUSINESS PLAN FILED DATE FILED c) ,a � � YES NO �-7'fo CHECK# PERYIT AMOUNT FEE CODE RECEIPT# BY: T ^ 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.13 FORM A(3-2-88)