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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD J hE,,t � �tif, ` ar„ 1 FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �" SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -o . o l=/ COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��Foa�`" MARK ONLY F-11 NEW PERMIT F-13 RENEWALPERMIT ars OF INFORMATION ❑ 7 PERMANEN /g�pSITE F� ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �� S -4 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) A G11 FACILITY/fi{.TE NAME /� CARE OD SS INF MATION - ADDRESS /( NEAREST CROSS STREET -!J(_/./•�✓'_1 qL_ ❑ PAA1A95NN 0 STATE.AGDO J N Lp /(„JLA7 ��[ ' •- n WIP 011 0 LOCALAGExLY 0 FEDERAL AED0 /LN/�"�A CJS 0 IIll11Y1Wp1 0 WUNTYAGBILY CITY NAME STATE ZIP CODE SITE P NEN.WITH AREA CODE �U CA 7 d= 0 TYPE OF BUSINESS: ❑ DISTRIBUTOR ❑4 ESSOR -/BOX B INDIAN EPA ID# ❑ 1 GAS STATION ❑ 3FARM Z15 OTHER TRUST LANDS SERVATION OT ❑ ��"�� /S Z7 AT THUS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: AME(LAST,FIRST) PHO p WITH AREA CODE 3" 3s b Z86 A SA NIGHTS: NAME(LAST,F T) A HONE p WITH AREA CODE NIGHTS: AME(LAST,FIRST) PH E p WITH AREA CODE .c >Q S � � II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMECAREOf DDRESS INFORMATION MAILING or STREET ADDRESS I/BOX to indicate 0 PARTNERSHIP 0 STATE-AGENCY OO S ' ❑ CORPORATION ❑ LOCAL-AGENCY DERAL- GENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAM STAT ZIP CODE PHONE 1,WITH AREA CODE S -2- III. TANK OWNkR INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S MAILING or ST EET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE$L 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: 1. 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 R JURISDICTION If AGENCY A, FACILITY ID N N of TANKS BI SITE = ov r = I In I C) 100 CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAM g PHONE p WITH AREA CODE PERMIT NUMBER 23 PERMIT APPROVAL DATE f'[ffk— PERMIT EI (RATION DATE LOCATON CODE CENSUS TRACTS SUPERVIS R-DISTRICT CODE BUSINESS PUN FILED DATE FILE - 3 O o YES NO (O 14x, �I CHECK p PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If Y: \\\\ 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. ORM A 13-2-881