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STATE OF CALIFORPR WATER RESOURCES CONTROL BOARD 11.1 W. FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 O I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N CJ1 FACIU /SITE NAME CARE OF ADDRESS INFORMATI N Ic�A.n -Fo rea-F rod,c-�c-�P u l I i la n ADDRESS NEAE CROSS STREET ✓ in I ❑ PARTNERSHIP Ill STATE AGENCY p( 5 u n r i umPORATION 1:1 LOCAL AGENCY El FEDERAL AGENCY V` ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE TYPE OF BUSINESS: ❑Z DISTRIBUTOR ❑ 4 PROCESSORif INDIAN EPA ID # RESE✓Box RVATION or #of TANK's ❑ 1 GAS STATION ❑3 FARM R TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE IIIYLkap P ONE#WITH o NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST PHONE#WITH AREA CODE L( 1 Is6 644)qDON 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME R( n /l CARE OUQORESSNFORMATION i MAILING or STREET ADDRESS [KJ V 1^ 1 , ✓Box to indicate("/~L ❑ PARTNERSHIP ❑ STATE-AGENCY 3 s - N V i W 9 11 CORPORATION ElLOCAL-AGENCY11 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAT ZIP D PHONE#,WITH AREA CODE c V_) Q dOS IMcg �l�ti �3Y III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax toindicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEOERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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# JURISDICTION# AGENCY M FACILITY ID# M o1 TANKS at SITE ® = = 10 10 10, ayS1010101 CURRENT LOCAL AGENCY FACILITY ID T# APPROVED BY NAME PHONE M WITH AREA CODE .1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EX%RATION DATE LOCATq CENS�XRACT# SUPERVISOR-018 RI T CODE BUSINESS PLANFILED ❑ DATE FILED I YES NO Cl�.�,> I 3 W 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(3-2-68) DATA PROCESSING COPY 0.