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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A : UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° COMPLETE THIS FORM FOR EAC ACILITYJSITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 19 5 CHANGE OF INFORMATION ❑ T PN LY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION L r%J i9f d-r-� ADDRESS NEARESTC OSS SET STATE-GENU— tizo C) LOCLL-AGEC ❑ FH*Fk-AGV CP ❑ INT)IWOX ❑ mom-AGENLY CITY NAME STATE ZIP CODES _ SITE PHONE N,WITH AREA CODE / CA a S X 6 5�� r( TYPE OF B ESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bdx iI INDIAN EPA ID N N of TANK's GA55TATION ❑ 3 FARM ❑5 OTHER TRU5T LANDS ESERTIONor ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS AME(LA T,FIR T) f� PHONE It WITH AREA CODE o— 066 NIGHTS'. NAME(LAST,,FIR S TPHONE it WITH AREA CODE NIGHTS NAME(LAST,FtR T) PHONE 4 WITH AREA CODE C II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME V / �I juf�// CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box Io indicate ❑ PARTNERS0P ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ( h ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE / ZIP CODE 4 ` PHONEN,WITH A� D�� y i jam✓ 2 ) /q III. TANK OWNER INFORMATION & ADDRESS —(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY �r G IAPORATION ❑ 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{f}BOX INDICATING WHICH ABOVE ADDREU SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. YI- ❑ 111.❑ THIS FORM NAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION II AGENCY 11 FACILITY ID N M of TANK$of SITE FRRENT LOCAL AGENCY/FACILITY ID N .-^I. APPROVED BY NAME PHONE N WITH AREA CODE [� C/1/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES C] NO 3 ` I LCHECK# f PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT S BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST YORE TANK PERMIT FORM 'B' APPLICATIONIS), UK 'THIS IS A CHANGE OF SITE INFORMATION ONLY FORM A(3-2-98)