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STATE OF CALIFORNIZ WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM m , SITE AGILITY/SITE, INFORMATION and/or PERMIT APPLICATION ogNP �--1� COMPLETE THIS FORM FOR EACH FACILITY/SITE 'I MMK ONLY L'7' NEW PERMIT � 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION � ' PERMANENTLY CLOSED SITE ONE ITEM � 2 INTERIM PERMIT � 4 AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE n Z 10 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF A DRESS INFORMATION ��y� 1 NEAREST CROSS STREET "eA�i/�0 PAR NERSHIP 0 STATE-ANLV GEN ADDRESS WORATION 0 LOCAL 0 FEORIAL AGENCY 00 UOiM INDIVIDUAL 0 CWNWACRa W CITY NAME (/� STATE ZIP CODE SITE PHONE#WITH AREA CODE I'J atir.�ec�✓ CA TYPE OF BUSINESS 2DISTRIBUTOR 4>QEMOR ✓Box if INDIAN EPA IDN J= TANK'N I� RESERVATION or ATTHIS ❑ SITE i^ 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST __Q�,/- PHONE#WITH AREA CODE DAYS NA E(LAST,FIRST) PHONE N WITH AREA CODE V/ O� !/ NIGHTS: AME(LAST.FIRS ONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION SII MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. 1L El 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 �I COOU�N�TYY## JURISDICTION N AGENCY# FACILITY IID�At �y) #of TANKS at SITE el 6- U15 1 10 10 1 O CURRENT LOCAL A ENCY FACILI IDN APPROVED BY AM PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE MIT EXPIRATION DATE PCIE DE CENSUSTMCTN� SUPERVISRICT CODE BUSINESS PUN FILED DATE FILED YES NO PERMRAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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(32.881 UUUl 'Ys DATA PROCESSING COPY �I-w/