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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a FORM `A': UNDERGROUND STORAGE TANK PROGRAMSITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONz to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY OSED SITE 1-4 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -4 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION vI c Lxtr �((L ADDRESS C NEAREST CROSS STREET ✓G O"OI� ❑ PARTNERSHIP ❑ STATE AGENCY / C. /n - u/ o fiON ❑ LOCAL AGENCY ❑ FEDERAL AGENCY (� INDP/IDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 57/0 r�AE fon CA fS43v i TYPE OF BU ESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box 4INDIAN EPA 10 a b 7 GAS STATION ❑3 FARM ❑ 5 OTHER RESETRUST LANDS ATION or ❑ alc-- N of TANK's ATTHISSITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE Aqd_r � /m nPHONE N 5,40"w_ NIGHTS: NAME(LAST.FIRST) WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 54 Ke— 5'rr^'a- H. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ra /'mail E . f- / MAILING or STREET ADDRESS ✓Box la ir,0icate ❑ PARTNERSHIP ❑ STATE-AGENCY / f� ❑ C��PPPPB8FFATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY /l IH�IINDIVIDUAL Cl COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE e%f 95%X01 l7os 9b.s-vk7a Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 54f 17%e 45 7G MAILING or STREET ADDRESS ✓Rort oicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ PORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY 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: L ❑ I. 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID It N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE AE /m / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCATIONDE CENSUS TRACT0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 3 YES NO �,y_PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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-BB) `r DATA PROCESSING COPY f