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. ... .: .,ns... . ,.,.M,.. m.,..,., . wvtir.+rg.. a '^""T'ABPIIPAg4$SI�'SA+-#;l);al�ss•+n:xFT'n:,9+s..n—., STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 4p: �yA FORM 'A': :. UNDERGROUND STORAGE TANK PROGRAM = ° n�a SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM11 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 10 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 0o nil I s r n� �v,�, ADDRESS NEAREST CROSS STREET ✓_�efTI,lndrs@ ❑ PARTNERSHIP ❑ STATE-AGENCY IV LITCORPORATIONCORPORATION 13 LOCAL AGENCY El FEDERAL AGENCY Lq e-r ❑ INDIvOAI ❑ CO.IAGEND CTi CITY NAME STATE ZIP CODE ITE PHONE#,WITH AREA CODE N Sfo c (C CA 5a a M T-5- TYPE OF BUSINESS'. ❑ 3 DISTRIBUTOR ❑ 4 PROCESSOR '/Box if INDIAN EPA ID # ❑ I GAS STATION 3 FARM 5 OTHER �L�0 ,RESERVATION or AT THIS SITE [:] TRUST LANDS ❑ —�^ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) 0 n �� P 0©�WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(UST,FIRST) SaPHONE k WITH AREA CODE rn �- II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION SQ Facl` �- 42 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION .sce MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. II. ❑ 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) LATE # LOCAL AGENCY USE ONLY COUNTY# JURISDICTION At AGENCY# FACILITY ID# #of TANKS at SITE m aor = 1600 CURRENT LOCAL AGENCY FACILITYNO I+ APPROVED BY('NAME PHONE#WITH AREA CODE PERMIT NUMBER. lm/Lh/,y'N' PERMIT APPROVAL DATE PERMIIT`^EXPPIRATION DATE 71a,0 L OCATIONE CENSUS TRACT* PERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 i J O � YES � NO � 7 /3 Sr PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 1 1 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(3-2-BS) . S DATA PROCESSING COPY