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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "e FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m 1�F-J COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 711 N PERMIT 3 RENEWAL PERMIT NGE OFINFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Z 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) so FACILITY/SITE NAME CARE OF ADDRESS INFORMATION NI F r Olv QIu S L ADDRESS NEAREST CRO SZIP Bo e ❑ F.MNEASIIP ❑ STATE-AGENCY N Fre efRrj RFORATIGN ❑ LocnLAGENw ❑ FEDT L-ACENcr —I ❑ Iwivioua ❑ COUNIYAGENCY � CITY NAME f I STATE ODE SITE PHONE$1,WITH AREA CODE 53� 5 TYPEOFBUSINESS: p DISTRI TOR ❑4 PROCESSOR ✓Bo%dINDIAN EPA ID# ❑ 1 GAS STATION ARM ❑ SOTHER TRUST�LANDS or If*I TANK-B ❑ IvQ tl/L:d AT THIS SITE a-- 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 cO l Doti a4 s�Fr -7_) , NIGHTS: NAME(LA FIRST) PHO E#WITH AREA CODE NIGHTS: AME(LAST, ST) PH NE N WITH AREA DE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION .571'110 __ MAILING or STREET ADDRESS ✓Box to irdwao' ❑ PARTNERSHIP 13STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION SA--).A%:-7 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L 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 8 SIGNATURE) PATE I LOCAL AGENCY USE ONLY COUNTY k JURISDICTION k AGENCY N FACILITY ID k p of TANKS at SITE 3 I 10o0 CURRENT LOCAL AGENCY FACILITY ID•1 JC APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPPRRrOV LO A MIT PIRAT DATE (J s lkfl LOCATION CODE CENBUB TRACT N PER SOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED L. - YES NO ❑ g CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If T: 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 ONLY. FORMA(3-258) �. DATA PROCESSING COPY i