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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWALPERMIT E]5 CHANGE OF INFORMATION a NENTLY CLOSED SITE ONE ITEM 2INTERIM PERMIT 4 AMENDEDPERMIT 6 TEMPORARY SITE CLOSURE yr I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) IG FACILITY/SITEME A E OF ADDRESS INFORMATION ADDRESS �/� 'V,'�j'j'�A, NEAREST CROSS STREET ✓Box to mWe ❑ PARTNEASHP ❑ STATEAGE10 N 2oZ JAI.. v I M ❑ COAPOMTION ❑ LOCk MENC/ ❑ FEDEPAL A090 CITY NAME /.�V_ V-��1 LJ/`p ❑ INDWIDWl ❑ CWVY AGENCY SATCA 21PCODE SITi;HONE p,WITH��^ OIV TYPEOFBUSINESS: ❑231STRIBUTOR E]4 CESSGR ✓BozpINDIAN EPA ID 4 iv Nal/1/TANKY ❑ 1 GAS STATION ❑3 FARM OTHER RESERVATION or ❑ TRUST LANDS of TANICTE(/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRF PHONE p WITH AREADE DAYS: NAME(LAST,FI ) O PHONE N WITH AREA CODE o 6 NIGHTS: NAME(LAST,FI ) PHONE#WITH AREA CODE NIGHTS: NAME(LAST, ST) PHONE#WITH AREA ODE N el Zo a II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME n ^ , CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS to indicate El PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA ODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME s�+ 'I CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS 'to PARTNERSHIP intllcete ❑ PARTNERSHIP 1:1STATE-AGENCY D 1 �` ❑ INDIVIDUAL 11 COUNTY-AGENCY El LOCAL-AGENCY 11FEDERAL-AGENCY CITU NAME -c STATE ZIP7 / PHONE ARWMDE IV. LEGAL NOTIFICATION AND BILLING ADDRESS cP&/ CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N #o1 TANKS of SITE CURRENT LOCr AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE Co p Z PERMITNUMBER PERMIT APPI{OVAL GAT PERMIT EXPIRATION E LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED © 23 �V 0 YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: T S 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. R A(3-288) DATA PROCESSING COPY