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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 'o COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ TLY CLOSED SITE F+ ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 711 4 1.FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) F-+ FACILITY/SFE E ,44- CARE OF ADDRESS INFORMATION N( (zN ADDRESS NEAREST GROSSS STREET Mraft FIIM PARINP ElSTATE AGENCY ,V 1/'f / 0S6 TION ❑ LOMAGDILY ❑ RDEMAGEN INGMWAI ❑ COUO(-AGENCY CITY NAME ^� STATE ZIP C DE O� SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box X INDIAN EPA ID x J ❑ 1 GAS STATION f TANK" ❑ 3 FARM ❑ 5 O1HER TRUSTYLANDS ATION OT ❑ AT THIS SITE 1 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: M PHONE k WITH AREA CODE DAYS: Nga1E(LAST,FIRST) PHONE N W TH AREA.C'ODE NIGHTS: NAME(LAST,FIRSTe PHONE N WITH AREA CODE NIGHTS. NAME((L'A'�ST�,FIRST)� PHONE N WITH AREA CODE - 45 �G a..10T& II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION I�SSoG N ❑ PARTNERSHIP 11 STATE-AGENCYMAILNG or STREET ADDRESS E CORoPON 11 LOCAL-AGENCY ❑ FEDERAL-AGENCYO, BO U ❑ INDIVIDUAL 11 COUNTY-AGENCY CITY NAME S /7<A,/ STATE, 21P CODE PHONE=EA CODE_�/ III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) 7G NAME S 11r ( CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS to indicate PARTNERSHIP ❑ STATE-AGENCY CORPORATION ElLOCAL-AGENCY [IFEDERAL-AGENCY ( O ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE x,WITH AREA CODE 57<�l� SZ/3/boa _y IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ 11. ❑ 111 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND 007RECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION x AGENCY N ILITY ID a - x of TANKS at SITE 39 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY ME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTN SUPERVIBp"ISTRICT CODE BUSINESS PLAN FILED DATE FILED ¢[� O f O YES NO Z ZO—OG CHECK x PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IS'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-881 v � DATA PROCESSING COPY ♦.r j