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STATE OF CALIFORNIIX WATER RESOURCES CONTROL BOARD " l' FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� o COMPLETE THIS FORM FOR EACH FACILITY/SITE �"'°�w-"—'" MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ NTLY CLOSED SITE I I–a ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 00 a) FACILITY/SITE NAME xl ` CARE OF ADDRESS INFORMATION ADDRESS 1} 1 NEAREST GROSS STREET ✓Aox to iHvxle ❑ PARINEASHIP ❑ STATE AGENCY (�L1A. 7 JZ(A V /17�G ❑ NpIDUAL10N O LOM ry GE CY Cl FEDERALAGENCY CITY NAME STATE CA ZI(Q / SITE PHONE M,WITH AREA COD TYPE OF BUSINESS'. 2 DISTRIBUTOR ElN 4 PROCESSOR ✓ ox if INDIAN EPA ID /� I TANK's RESERVATION or Mo ❑ I GASSTATION E] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE A/A-N o M U —8 OS 5/ > L —.?7.2— 6o0 NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 1:1 STATE-AGENCY C ❑ CORPORATION ClLOCAL-AGENCY ❑ FEDERALAGENCYST Q YI C.. O Sf ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE SSI " u z-A o lG III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME p DARE OF ADDRESS INFORMATION , '"1G S G D u 60 vin d. MAILING or STREET ADDRESS _7 .yp qq n�/L.— ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY / Smµ DA,,J �I�ICVU ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITU NAME 'J� & STATE ZIP CODE / Pt10N)6 WITH ARE7 A CO�E— IV. LEGAL NOTIFICATION AND S\BILLING ADDRESS 3 CHECK ONE(1)BOX 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(PRINTED&SIGNATURE) / DATE ]&.I eiv E LOCAL AGENCY USE ONLY COUNTY R JURISDICTION a AGENCY a F ID a M of TANKS at SITE 3 �{ a v CURRENT LOLAGENCACILITY APPROVED BY NAME PHONE a WITH AREA CODE PERMIT NUMERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONnG ;ISUPERVI! DISTRICTFODE BUSINESS PLAN FILED DATE FILED (/ vYES ❑ NO ❑ D�Z--gCHECKa SURCHARGE AMOUNT FEE CODE RECEIPT M 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(3-2-88) C S"' DATA PROCESSING COPY