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STATE OF CALIFORNIV WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE -11 MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ANENTLY CLOSED SITE 1� LONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE v 11-C4 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 49 FACILITY/SITE NAME (f_p.g'I CARE OF ADDRESS INFORMATION �onYTihc — rL( �� ADDRESS NEAREST CROSS STREET ✓&'. Wcae ❑ PARINEHSHIIP ❑ STATE AGENCY I �S O � ❑ NRAVBU,LLTI� ❑ COUNTY Cl L�AGENCY ❑ FEGEHALAGENLY CITU NAME �� STATE ZIP CODE / SITE PHONE p,WITH AREA CODE cA S 3 '7 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓BOK it INDIAN EPA ID p ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS TION or ❑ X of TANK's AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE NWITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE&WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to mdl.ale Cl PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INF OHMARON MAILING or STREET ADDRESS ✓Box wmn cale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE&,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. ❑ it. ❑ 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# JURISDICTION If AGENCY M FACILITY ID N X of TANKS at SITE F2-97-9 00 / =7 1 O ,�) O CURRENT LOCAL AGENCY FACILITY ID& APPROVED BY NAME PHONE Y WITH AREA CODE " Ge 't 2 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO�N{CODE CENSUS TRACTS l SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED U JJ V 7- YES NO � CHECK& PERMIT AMOUNTSURCHARGE AMOUNT FEE CODE RECEIPT& BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UN L THIS IS A CHANGE OF SITE INFORMATION ONLY. - ORM A(3-2-aB) '�3� L' • DATA PROCESSING COPY