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01 STATE OF CALIFORNIA' WATER RESOURCESCONTROLBOARD ... FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE + FACILITY/SITE, INFORMATION and/or PERMIT APPLICAT11ONora A COMPLETE THIS FORM FOR EACH FACILITY/SITE FMARK ONLY El NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIMPERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE YO 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACIUTYMTE NAME CARE OF ADDRESS INFORMATION �iR Fr.�FsroY�c �357 ADDRESS NEAREST CROSS STREET ✓BNBnYAY ❑ PNRNEPBw ❑ STATEWA10 �dD �f/. �♦i DoA 4Pc L<NII L(" o isfai LIM O LOX CDMnA AUN CY ❑ rFnERu ACE14Y CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA COOE :5 Tae,( CA TYPEOFEUSINESS: ❑ 20WWBUIOR ❑/PROCESSOR ✓Box. INDIAN EPA ID N ❑ t GAS STATION ❑ 7 FAWA �THEfl RRUSTVLANDS a ❑ AT 711I of 115 BITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE Y WITH AREA CODE V ERnd w(� 213 R27-7010 NIGHTS: NAME(41ST,FIRST) PHONE Y WITH AREA CODE NIGHTS: NAME(EAST,FIRST) PHONE 1 WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMA110N IadV l S. w.�55EP./`r TR vsT MAILING or STREET ADDRESS ✓BOY W.w"I1 ❑ PARTNERSHIP ❑ STATE-AGENCY 117713 D�(V� 13CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE V.WITH AREA CODE S5AG1211mflvT- > G� I lTg2_Z III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFOHMATION O/V/o 5. -/Av_S7- MAILING a STREET ADDRESS ✓13"b eW"o ❑ PARTNERSHIP ❑ STATE-AGENCY ,,t7z� s 13 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY C INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE Y,WITH AREA CODE CA s 2, IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. 111.❑ 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 F JURISDICTION E AGENCYII FACILITY ID F N DI TANKS at SITE 3 °I = = l0lc-,;) lz45 10 10 1 i CUR REEW LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE 1 WEEN AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT F SUPERVISOR-0141FRICT CODE BUSINESS PLAN FILED DATE FUJED YES NO ❑ GC q V CHECKI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIRI BY: ,,`` �� V` THIS FORM MUST BE ACCOMPANIED BY AT LEAST"'OR MORE TANK PERMIT FORM 'B'APPLICATION($), I'"•%S THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2.88)