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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 : t o / (J COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N v I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) A FACIU E NAME CARE O ADDRESS INFORMATION AII ADDRESSllql RESTACRO STREET ///�� ✓Bmlepl w ❑ PAWNEE IP ❑ STATE AGM 1:1 COFIRNAT 0 Lox Kea O v IlXir ❑ ItUMD1Al ❑ COWM-AGBILY CITY NAME Q STATE 21P CODE SITE P ONE N,WITH AREA CODE 42cA vc) 3G�-slsl TYPE OF BUSINESS ❑2DISTRIBUTOR ❑/ R ✓Boz A INDIAN EPA ID n ❑ I GAS STATION ❑ 3 FAPoA 5 OTHER TRUSTmLANOS ATION or ❑ - •M TANKa AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME LAST,FIRST) PHONE Sl ARE A CODE DAYS: NAME(LAST,FIRST) )HONE N WITH AREA CODE IG NAME( ST,FIRST) PHONE 0 WITH AREA CODE NIGINAME(LAST.FIRST) 7p�H2ONE a WITH AREA CODE J Yb / YYYY II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) N CAREIF ADDRESS INFORMATION g A MAILING or STREET ADDRESS V Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY EDER L-A ENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE)'WITH A EA CODE Z i f vS III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILINGS,STREET ADDRESS ✓Boz to indbate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. II. ❑ Ill.❑ 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 b JURISDICTION N AGENCY# FACILITY ID If R of TANKS at SITE oo 3 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE MITE PIRATION DATE LOCATION CODE CENSUS TRACT N SUPER VI OR-DISTRICT CODE BUSINESS PLAN FILED Imo/ DATE FILED p 9 '1 7 '� l YES [-] NC> o (� l L ri { CHECK# f PERMI AM SURCH RGE JIMOUNT 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 ONLY. FORM A(3-2-88) ....rI DATA PROCESSING COPY ../ J