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i Se'au��a1 j�f STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s, 1 FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V NL^ Z ® „ �� SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION too `e G/ COMPLETE THIS FORM FOR EACH FACILITY/SITE MMK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 P CLOSED SITE -4 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) G> CARE OF ADDRESS INFORMATION FACILITY/SITENAME- T'?F1 �M�M1�1 I✓�Y�/V�lXC//. NEAREST CROSS STREET ✓Bwloin TO 0 PPATNEASNIP ❑ STAIE-AGDIC/ ADDRESS 5 0 ROMMAPDN 0 cotmTr CEN ❑ FT➢EPPI AGENLY 0 INDMWAL 0 WUNIV#GENCI IT STATE 21PCODE SITE PHONE p'WITH AREA CODE �/' CITY NAME CA Z 3 V TYPE OF BUSINESS: ❑3 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA IVU Y R of TANK'S n RESERVATION or AT THIS SITE 5 OTHER fes" I GAS STATION ❑3 FARM ❑ TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) PPHONE p WITH AREA CODE HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) DAYS: NAME(LAST,FIRST) / A-Ln.So1✓ oN 2p4-234-3So d NIGHTS: NAME(AST,FIRS ) PHONEM WITH AREA CODE NIGHT : NAME(LAST,FIR PHONEM WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME �•6 CARE OF ADDRESS INFORMATION I 6s MAIDNG or STREET ADORE I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY O ^ 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY Z 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE w� o drS 4_U 9si3yf —SZ -9857 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME ` CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS !/w I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS FCHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. II. F-1 111.❑ 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 M FACILITY ID R R of TANKS M SITE CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE N WITH AREA CODE III NN 6 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECKN ODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDG 0 � "Z6 YES NO p PERMIT AMOUNT I SURCHARGEAMOUNT FEE CODE RECEIPTY 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 .,.