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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD _ w FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ao Z SITE 113 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE $() Q I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N FACILITY/SITE NAMEn CARE OF ADDRESS INFORMATION even o-Ffh 1. b raA.l AvC ADDRESS NEAREST CROSS STREET ✓Bmbixiwo ❑ PA EASIIP ❑ STATE AGENCY ` O N ❑ ODWMINDMDUTIION LOX AGENILp ElFEDSVLMUD CITY NA STATE ZIP CODE SITE PHONE N,WITH AREA CODE c_kjo IN) CA 95e20 209- e14 f??17 B TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑ 4PROCESSOR '/Box if INDIAN EPA ''ID/ I6 # 0 o TAN ❑ ESE i GASSTATION ❑3 FARM OTHER TRUSTVATION LANDSV ElM K I V ATTHISSITE I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME QRST,FIRST) PHONE Al WITH AREA CODE Q N + FroNk 20`f- zt-Ih17`7 C Ili NIG S: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE - h -sYP N II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME �J CARE OF ADDRESS INFORM ION eapN (� 85l �k l6� MAILING of ItoSTREETA R ✓ Oz to intlicale ❑ PARTNERSHIP 0 STATE-AGENCY ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY / � INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMI STATE ZIP P4,DDE PHONE p,WITH AREA CODE �T III. TANK OWNER INFORMATION &ADDRESS - (MUST BEC MPLETED) NAME q CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓ oz l0 intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY oRPORATION ClLOCAL-AGENCY ❑ FEDERALAGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMEO �� STATE ZI ODE PHONE#,WITH AREA CODE 5 / IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ if. ❑ III.J4 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# AGENCY M FACILITY ID# #of TANKS at SITE 010 1118 17 10 1 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE E �N PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT• SUPER SOR-DISTRICT CODE BUSINESS PLAN FILED OATEFIED�/ 2 Z YES ❑ NO OAT/ d O CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST"I OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1' FORMA 13-2A8) DATA PROCESSING COPY ;c� _ ��