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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM - o SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE FMARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION I PERMANENTLY CLOSED SITE FJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 4bh FACILITY/ TE NAME CARE OF ADDRESS INFORMATION ADDRESS , 1 1 NEAREST CROSS STREET ✓ 10'Ixjow ❑ PARIAERSHIP ❑ STATE AGENCY Lp 0(4 Q.kA Le •rxg, � ❑ IN�MD AI O CGaNTY'AAGENCY ❑ FEORw.AGBucY CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE L a CA CIS)t40 2_ 6c1314 Z TYPE OF BUSINESS: [EI-2-DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box 4INDIAN EPA ID N RESERVATION❑ or Nof TANK' RUSLANDS5OTER k_A1 GAS STATION [:] 3FARM ATTHISSISTE j EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMEnLal , CARE OF ADDRESS INFSATIT I K� , `^ MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY -- � 11 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 3 (1lfl Nt4L I ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE - III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME ^ ._L CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS LA` ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ 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. 11. ❑ 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 M N of TANKS at SITE E I OO .zl3 -�- 1 101010101 CURRENT LOCAL AGENCY FACILITY IDN F_,^ APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROO1V1.AL DATE PERMIT EXPIRATION DATE L OCATION CODE CENSU�RACT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DA E G ll YES 0 NO � N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN sly THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIO MY - Y 'FORMA(3-2-BS) v�ll\ �"�, DATA PROCESSING COPY �