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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD VP. w FORM `A': UNDERGROUND STORAGE TANK PROGRAM �a SITE O FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE 7 L MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PEPAULENLY CIDSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a 1 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILI /SITE NN�2"A'� wo ` CARE OFA D ESS INFORMATION g&L_ C/ l%Fn L-/' jA1 N ADDRESS NEAREST SSTREET liq ✓ twiiaw ❑ PMIMFWP ❑ TATE AGENCY 'x1 rlwDuAL ❑ WUMYA N EN C1 NAM D STATCA ZI CODE �� ITE PH0(4E#.WITH YEA CODE C TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 P ESSOR ✓Box if INDIAN EPA ID a L S W TANM, RESERATION ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDSIN ❑ Al AT TN1881TE 02� EMERGENCY CONTACT PERSON(PRIMARY) EMER ENCY CONTACT PERSON(SECONDARY) D NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. N E(LAST.FIRST) PHO E#WITH AREA CODE A4WVNtw�v - s A NIGHTS: NAME(LAST,FIRST PHONE p WITH AREA CODE NIGHTS: AVE(LAST,FIRST) PH N #WITH AREA CODE 20? -`.mob l S A S 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAMEoCARED DRESS INFORMATION �' MAILING or SIRE AyDRESS ✓ Ox m indicate ❑ PARTNERSHIP 11STATE-AGENCY J+� CORPORATION ❑ LOCAL-AGENCY ED -AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME - STyTE_ ZIP CODE PHONE"WITH R ODE 111. TANK OWNER INFORMATION &ADDRESS - (MUST BEA/CCOO�MPLETE9D•))) 3`�I/ NAI) CARE OF 9D R SS INFORMATION ♦ IA/J MAILING or STREET ADDRESS ✓�9ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY L�CORPORATION ❑ LOCAL-AGENCY F DER G CY ` 13aVol ❑ INDIVIDUAL ❑ �COUNTY-AGENCY CITpNAME�, STATE R ZI .1 2Y(J 20 g_WITN33A _A CODE y IV. LEGAL NOTIFICATION AND BILLING ADDRESS CC v^�L1 CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID If Bof TANKS N SITE / 3 106 1 D CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE Lop/Z, d PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTIf SUPERVI R-DISTRICT CODE BUSINESS PLAN FILED D FILE / YES NO ❑ CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# r Illy: 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) - - DATA PROCESSING COPY >1.4/ n