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STATE OF CALIFORNI* WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAMU 1 j <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONto <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE1-4 <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 rV <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 00 <br /> I" <br /> FACILITY/BtTENAME / CARE OF ADDRESS INFORMATION <br /> ADDRESS 1 , A NEAREST CROSS STREET ✓ 0Axk , ❑ PARFNEI511` El FAR AGENCY <br /> I l`�'11e. ❑ INDI <br /> �pM�T10N 11 13 LW LAAGENCY ❑ RDE�L AGENCY <br /> CITY NAME llYv STATE ZIP ODE �� SITE PHONE M.WITH 3%q3 <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOfl -/Box if INDIAN EPA ID p 5 <br /> RESERVATION or ISI T ' ,A N of HIS SI <br /> ❑ I GAS STATION �RM ❑ 5 OTHEfl TRUST LANDS ❑ / W YlX-� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE 0 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE b WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME ^ CARE OF ADDRESS INFORMATION <br /> Q� ^1T �,c <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMEqq � � yy� CARE OF ADDRESS INFORMATION <br /> WY f� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ it. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> 1 LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY R FACILITY IDN N of TANKS BI SITE <br /> [3 10 161613 <br /> CU/R�RE�N/AT��L�AO'C7A�/L AG�ENC1Y FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVI OR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 3 YES ❑ NO [] 5 <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> A1/ DATA PROCESSING COPY Ili <br />