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�yG aUo STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V z ® A,°�� SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o r 10 COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE A I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) CJI M/SiTE ) RE OF ADORE INFORMATION ``/-✓J N RE T ROSS STREEf ✓Bm Nirbrsle ❑ PAWNEF 11` ❑ STATE AGENCY Iy 1 ' INDIIDELCOWUAALI� O CGuNTfAcs ❑ IEUDw-ACB+cYv L"�ISTATE /ZJJp CODE SITE PHQNE JZ ARE DE( �/ SLJ1 (Al❑ p DISTRIBUTOR ❑ CESSOR ✓Box if INDIAN EPA ID p l M of TANK'a I RESERVATION or ❑ ATI HIS SITE 0 j ❑ I GAS STATION ❑3 FARM 6 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) D YS'.4NAME, T,FIRST PHONE#WITH AREA E DAYS- ^AME(LAST,FIRST) PHO #WITH AREA CODE VA Z � 1 l*RST FI T) PHONE 9 WITH AREA CODE NIGH: ME(LA1!64 3 ST,FIRST) PH NE WITH AREA COOE 6�- Zl vo11. PROOWN R INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILIN or STREET ADDRESS ✓box to indicate ❑ PARTNERSHIP EFEDERAL AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY -AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMES CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 11 LOCAL-AGENCY ❑ 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: I. II. ❑ 111.❑ 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 M JURISDICTION R AGENCY N FACILITY IDN N of TANKS at SITE b 1 CURp{NT LO �GF�[7CY FA ILITY IDN APpROyF,p BY y `E A V� PHONE N WITH AREA CODE PERy1T NUMBER PERMIT APPROVAL DATE O,,AV'(�/– '/7[PERRIN EXPIRATION DATE or LOCATION CODE CENSUSTRACTN SUPERVISOR-DIST111CT CODE BUSINESS PLANFILED / OA L—w 95 ...Tli YES NO CHECK# PERMIT AMOUNT SURCHARGE AM UNIT FEE CODE RECEIPTIt 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(3-2-08) DATA PROCESSING COPY vw0l