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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a FORM A: UNDERGROUND STORAGE TANK PROGRAM SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® ; COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENT CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME ^ , CARE OF ADDRESS INFORMATION r �Q ADDRESS e, N R/f,$TT,CROSS STEEEP ❑ OM MTM 0 Cl POCAL ASHP 0 El STF�EAGY CITY NAME ^ / STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS- ❑ 2 DISTRIBUTOR ❑ 4ESSOR ✓Boa if IND IAN EPA ID # RESERVATION or ,�,{ Mol TANK'# ElI GAS STATION El3 FARM OTHER TRUST LANDS ❑ - / ✓" •"�� AT TNI$SITE I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE h C�4 `f 700 l NIGHTS: NAME JUST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME //'' CARE OF ADDRESS INFORMATION WJ�^, 9--6& MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP - 0 STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 1] STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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# JURISDICTION E AGENCY E FACILITY ID E S of TANKS N SITE " � D14A I 'f OS 010 / CURRENT LOCAL AGENCY74CILITY100 LAPPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATEPERMIT EKPIRATION DATE LOCA N C DE CENSUS TIIACT SUPERVISOR-DISTRBUSIME88 PLAN FILED DATE FILED 2 YES NO CHEC # PERMIT AMOUNT SURCHARGE AMOUECODE 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 ONL . FORM A(3-2A8) \ ,� C6 .w