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_.: —..—:..-,g. � --......tea.--_.... _,.-..,r.-,..,s--,�.,,,�...—._f__._�._ ._.-.cr•+a-..-..,.'-..e.weer.,.,.�.y�""°,F:R�R'FnY..a.r�a.�>.._.,,�,,,r._.r„�.�,�c.. v.,.-..,�;.�,,. � z STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 C_ COMPLETE THIS FORM FOR EACH FACILITY/SITE �'"��""•` MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANE LY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5� Cn I.FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) � FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Fool-f P?_O+ s' CC or x N; ( o,A ADDfl �-p NEAREST CROSS STREET ✓ Wnddda 0 PWMRAW 0 STATE AGEtCr IffOS S. 1 �5 � VG O CORPORATION0 INDMOUk0 LLOOC GDO ❑ IMMA00 UNTYAGENCY CIN NAME STATE I I ZIP DE SITE PHONE N,WITH AREA CODE >v 5206 2091- b - /23 TYPE OF BUSINESS: ❑2 DISTRIBUTOR [ fRXESSOR ✓Sox d INDIAN EPA ID M ❑ ❑ 0 TRUST LANDS RESERVATION 01 ❑ AT HIS SITE 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) PHONE At WITH AREA CODE DAYS: NA (LAST,FIRST) PHONE N WITH AREA CODE „ ak -y/2-3 � NIGHTS: NAME(LAST. IRST) PHONE N WITH AREA CODE NIGHTS: AME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 12 eN �o t(C icAalso+� MAILING STREET ADDRESS IL J 0 0 xlo indicate 0 PARTNERSHIP 1:1 STATE-AGENCY CORPORATION LOCAL-AGENCY FEDERAL-AGENCY ,Q, er 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE �� 45AO1-3o3t Ill. TANK OWNER INFORMATION &ADDRESS —(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Saws s j MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY I 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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: I. ❑ 11.4z 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) DATE LOCAL AGENCY USE ONLY COUNTY a JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE ffa 1010 a I loll 10 1 C) 10 10 CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE rItLX/y PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED, OI 2'3• GJ YES NO $ C CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ON . FORM A 132881 `� -'" DATA PROCESSING COPY �-