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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD F 1 FORM A: UNDERGROUND STORAGE TANK PROGRAM SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m, Io COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE Ir ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) I"L 1 FADL 'TE )' �I NAME CARE Of ADDRESS INFORMATION A / 0D�5 f r Nc, ADDRESS NEAREST CROSS STREET ✓ oiMrale ❑ PAMNERS4IP ❑ STgiE-AGENCY %�� r i+� CARPOPATION ❑ LOGL-AGENCY ❑ FEDEA4L-AGEND II �j�• ❑ INDmoWL ❑ COUNIYAGEND CITY NAME I STATE ZIP CODEE SITE PHONE a.WITH AREA CODE CA 9 -/ / TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 P SSOR I/Box it INDIAN EPA ID a ❑ I GAB STATION ❑ 3 FARM OTHER RESERVATION ❑t �Yw A'ATTHIS TANK' TRUST SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE Thor►1as a m (ao ?w—/PiL f3 �Ac nw ;ckeLr� Cao9 ��1pff Y NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE X WITH AREA CODE s �r+A e— Ca o q 4lo7-3a io Sa_,;, e Cd oQ G S- l�6 II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAMEP11 r / �1 ' C E OF ADDRESS INFORMATION T IIC"•F_` s�n;bAbrs MAILING or STREET ADDRESS ✓B oindlcate D PARTNERSHIP ❑ STATE-AGENCY O I ? ORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCV J ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(POINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION K AGENCY R FACILITY ID K K of TANKS at SITE ® = = o o0 CURRENT LOCAL AGFfY AGILITY ID X APP O D BY NAME PHONE X WITH AREA CODE La PERMIT NUMBER PERMIT APPROVAL D TE PERMIT EXPIRATION ATE 1 / D /a d ffe /a / LOCATION CODE CENSUS TRACT X SUPER SOR-DISTRICT CODE BUSINESS PL4A FILE DATE FILED �1 47A L.Ja1�1 YES NO a Al CHECK k PERMIT AMOUNT SURCHARGE AYOUNT FEE CODE RECEIPT X 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. FORMA(3-2-SB) (� DATA PROCESSING COPY )\