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STATE OF CALIFORNM WATER RESOURCES CONTROeBOARD F , W. FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PFRMANOTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 121 I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) I FACILITY/SITE NAME CARE OF ADDRESS INFORMATION S ADDRESS NEAREST CROSS STREET .( Q' ❑ "TNEHSIIIP ❑ STAi AGENC/ N GCORE I'ATION 0 LCGLAGENCI ❑ FEXRALAGENLV INOIVIOOAL Cl 0)[110AGENCY CITY NAME STATE ZIP DF SITE P Ep, TH AREA COO S �C!✓ CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N •of TANIPB ❑ 1 GAS STATION [:]3 FARM �OTHFA RESERVATION RUST LANDS or L] AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE VS' NAME(LAST,FIRST) PHONE N WITH AREA CODE ,e zo —9y - F lZaw'ELL !.� foo— 2 —s—SS NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,RRSI PHONE k WITH AREA CODE ,:��AIOAIVI Z61 6 II. PROPERTY OWNEA INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS {� /��/ ///''' Q B o indicate' 0 PARTNERSHIP 0 STATE-AGENCY i00I �,S Fes) (IIs' �r INDIV DUALPORATION 0 COUNTY AGENCY El11 LOCAL-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE P ONE N,WITH AREA CODE beleR - CA 1 q1920do —SSS 111. TANK OWNER INFORMATION & AD RESS - (MUST BE COMPLETED) NAME CAREOFADDRESS INFORMATION �t,c U , nn�s�E 4;f MAILING orST EET ADDRESS x to Indicate 0 PARTNERSHIP Cl STATE-AGENCY CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY G 0 INDIVIDUAL Q COUNTY-AGENCY CITY NAME C /Y _ -_I STATE ZIP CODE PHONE p,WITH AREA CODE CA— S_ G IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Eg 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) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION A AGENCY N FACILITY ID a Aof TANKS at SITE 39 1010 12- 3 010 6) CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE x WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE g N ODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D EF ED Z (� �Q YES NO PERMIT AMOUNT SURCHARGE MOUNT FEE CODE RECEIPTN BY:RM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. -Sed DATA PROCESSING COPY '�