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fi STATE OF CALIFORNIA WATER RESOURCES CONTROL BARD tits` °` . yYR[rrq ~f M1 L � V 7T FORM A: UNDERGROUND STORAGE TANK PROGRAM _ p SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE c40, RAS MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PE NTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ' I. FACILITY/SITE INFORMATION &ADDRESS-- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS D / J /� �,, /� NE ST<CROSS STREET P ✓Bo ID Micale ❑ PARTNERSHIP ❑ STATE-AGENCY ��. / +�..r��J��C.� r Cl IN S LCl ION O LO A AGENCY ❑ FEDERAL-AGENCY . CITY NAME � � STATE ZIP CODE SITE PHONE k,WITH AREA CODE CA Sa•l D TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID k N of TANK'a Armll OTHER RESERVATION or AT THIS SITE E] 1 GAS STATION E] 3 FMM TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) - PHONE it WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) HONE It WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &AD RESS — (MUST BE COMPLETED) NAME [ /' � � /) 'A CARE OF ADDRESS INFORMATION Nz MAILING or STREET ADDRESS rf(�/^Y^t' /�A�•[A�f`/•• ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY - ❑ (;DMPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY NDWIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE d,WITH AREA CODE )t-- ,r C'o I ct>'ot 1 D 111. TANK OWNER INFORMATION &ADDRESS — (MUS E COMPLETED) NAMErk /}� RE OF ADDRESS INFORMATION MAILING or STREET AD ESS Kn ///�� ✓B to' dicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ COR RATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY w V` RIVID L Cl COUNTY-AGENCY CITY NAME STATE ^ .IP CODE PHONE 7,WITH AREA CODE i C IV. LEGAL NOTIFICATION ND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION Ahu LALLING: L ❑ II. ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOv.*FDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) GATE �7 I LOCAL AGENCY USE ONLY COUNTY# JURISDICTION k AGENCY M FACILITY ID* N o1 TANKS at SITE [M I I Il E[ I I Etc) 10 1 !91 CURRENT OCAL AGENCY FACILITY ID APPRO E PHONE N WITH AREA CODE CO PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRA 0 SUPERVISOR--}DISTRICT CODE BUSINESS PLAN FILED DATE FILED D l a 3 Q D '3p� YES [] NO CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORA MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. RM A(3-2-881