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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM'A': UNDERGROUND STORAGE TANK PROGRAM SITE ,� FACILITY/SITE, INFORMATION and/or ERMIT APPLICATION �� COMPLETE THIS FORM FOR EAC FACILITY/SITE o.� Sf ^` elf Y ��ppyy a z MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT r 5 CHANGE OF INFORMATION ❑ L.R.ERUANIfNTLY CLOSED SITE I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT n 6 TEMPORARY SITE CLOSURE 1, tic/ I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME�J y� / / CARE OF ADDRESS INFORMATION I/ BA to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ADDRESS 30 "✓C /—�i�C/ NEAREST CROSS STREET✓Gar le 1-1PAnERWP 13 STATE-AGENCf MGNOUPlI� ❑ CWNIIAGEND ❑ BD IAO NC CITY NAME STATE. ZIPg4!DE � „/ SITE PHON -,WITH ARBA CODE TYPE OF BUSINESS: ❑ @DISTRIBUTOR ❑ I GAS STATION [:]3 FARM ❑ 4PROCESSOR ❑ 5 OTHER ✓BGx if INDIAN TRUSTMATION El LANDS or EPA ID a DATE FILED —L(/ a AT TNIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS'. NAM (LAST, FIRST) u PHOIiFeI WITH AREA CODE F - 6`-i DAYS: NAME (LAST, FIRST) I:u z '^ PHONE p W AREA CO E �a9-y 2 NIGHTS: NAME (LAST. FIRST) 91 A 0n1, A- ( PHONE a WITH AREA CODE c ;y NIGHTS: NAME (LAST, FIR ) I �Fr PH(JNO WITH AREA COOt L( R 90 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) N117/q( NAME ^ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/ BA to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILING or STREETADDRESS ORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE N WITH AREA CODE INDIVIDUAL ❑ COUNTY -AGENCY CITU NAME STATE ZIP CODE PHONE it, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION a FACILITY ID R M of TANKS at SITE 0 6 Da 10 MAILING or STREETADDRESS ✓B to indicate O PARTNERSHIP ❑ STATEAGENCY APPROVED BY NAME PHONE N WITH AREA CODE RPOBATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE N, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS I CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Yl 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 N AGENCYII, FACILITY ID R M of TANKS at SITE 0 6 Da 10 CURRENT LOCAL AOENCYEACILITY IDM G APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M dp SUPERVISOR -DISTRICT CODE %/�) BUSINESS PLAN FILED YES ❑ NO E] DATE FILED —L(/ CHECK PERMIT AMOUNT SURCHARGE AMOUNT 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 ONL 1 / FORM A (3-2-138) - / W�—� DATA PROCESSING COPY `^^� J