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:.y STATE OF CALIFORNO WATER RESOURCES CONTROPBOARD l" ..... ; EFL OF` FORM 'A': s SITE UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° COMPLETE THIS FORM FOR EACH FACILITY/SITE �FOP�N�P MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT ONE ITEM CHANGE OF INFORMATION 7 P NEN7LY CLOSED SITE 2 INTERIM PERMIT � 4 AMENDED PERMIT 6 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CD FACILITY/SITE NAM/ Q tom O (/Z CARE OF ADDRESS INFORMATION 00 ADDRESS VVI-1 1`� 1 TJ /` � NEAREST CROSS STREET to nirPARTNERSHIP ❑ STATE AGENCY CIN NAME CORPORATION(y I/V PORATION LOCAL AGENCY ❑ FEDERAL AGENCY ❑ INDIVIOOAL ❑ CWNTRAGENCY STATE ZIP CODE TYPE OF BUSINESS9 i SITE PHONE#,WITH AREA CCODDJ: ' 0 3 DISTRIBUTOR A AOCESSER ✓BO%if INDIAN EPA 0ID # S W�j D # b I GAS STATION E] 3 FARM 5OTHER RESERVATION or 1:1 - #DI7ANK'e TRUSTLANDS D EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE oars. �pME(LAST FIRST) AT CONTACT PERSON(SECONDARY) /1 ��F^ a n PHONE p WITH AREA CODE DAYS: NAME(Lq 7,FIRST) ,` PHONE p WITH AREA CODE NIGHTS: NAME(LASS FIRST) PHONE PHONE#WITH(AR,A(CODE NIGHTS:`NAME(LAST FIRST) O J✓l_ � PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE C NAME OMPLETED) S�fy /3 A CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS „J— /6 / p B 10intlicaa 13 PARTNERSHIP ❑ STATE-AGENCY OFF RATION ❑ LOCAL-AGENCY AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY- E3 FEDERAL-AGENCY AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME `^ J A CARE OF ADDRESS INFORMATION MAILING or STREETFApDRESS ✓6ox to indicate ❑ PARTNERSHIP ❑ TATEAGENCYCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY 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: 1. II 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY III�CODU,JTINTYYY## III JURISDICTION# AGENCY# FACILITY ID# -�—I—J #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIONpDATE LOCATION CODE CENSUS TTJRACT N �) SUPERVISOR-DISTRICT CODE BUSINESS PLANOFILED ® r<F3�0 �7 yT DATE FILED CHECK# !�V YES NO PERMIT AMOUNT SURCHARGE AMOUNT �— FEECODE RECEIPT* BY: THIS FORM MUST BE ACCOMPANIED BY AT FORMA(3-2-BB) LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1F • DATA PROCESSING COPY