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STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD 'f FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u l ' SITE �/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z ��( 1O COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY i NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE FJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D I. FACILITY/SITE INFORMATION III ADDRESS — (M TBE COMPLETED) -4 N FACILITY/ RE NAME i CARE OF DRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ loinduk Cl PARTNERSHIP 0 STATE AGPCr CANPOAATDN 0 LOCAL,GENCY 0 HOEHALAGEND n 0 INDIVIDUAL E DDUNIKAS, CITY IN MEI. " STATCA ZI Fz vz) ITE PH ITMJ F]EA� 7 TYPE OF BUSINESS ❑ p DISTRIBUTOR ❑ 4 CESSOR ✓Box it INDIAN EPA IDN -.1r M of TANK'ss RESERVATION or , / ❑ I GAS STATION ❑ 3 FARM 5 OTHEfl TRUST LANDS ❑ A AT THIS SITE b Z� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAM (LAST,FIR PHONE X WITH AREA CODE DAYS. ME(LAST FIRST) P p WITH AREA CODE v 36��55 b� A p NIGHTS. AME(LA FIRST) PHONE#WITH ARE4,00DE NIGH$: AME(LAST,FIRST) PROVE#WITH AREA CODE Wj)Ci7 o9S II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING C,STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAW CARE OF ADDRESS INFORMATION WAr� MAILING or STREET ADDRESS I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 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: L 2r II. ❑ Ill. ❑ 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 COUNTY41 JURISDICTION# AGENCY# FACILITY ID M #of TANKS at SITE ® � � 101iI s CURRENT LOCAL AGENCY FACILITY ID N APPR VQ ED BY NAME� PHONE WITH AREA CODE PERMIT NUMBER PER IROVALDA.TE PERMIT EXPIRATION DATE LLOCATIONE CENSUS TRACT# SUPE VIS - ISTRICT CODE BUSINESS'SN FILED HG ATE FILED �.PERMIT AMOUNT SURCHARGE AOUNT FEE CODE RECEIPT# 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(3-2-881 4/ DATA PROCESSING COPY • f