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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION V COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ ' NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT �� 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — IM11ST RF rnUDI aTrm ytn i'uit ••T^' r fto aIIFOaM�P ❑ 7 PERMANENTLY CLOSED SITE FACILITY/SITE ME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS L ❑ INDIVIDUAL ❑ COUNTY -AGENCY NEAREST CROSS STREET ✓ Bm to wocale E]PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ ST L PHONE It. WITH AREA CODE LOCA AGENCY ❑ FEDERAL AGENCY — — -- ElINDIVIDUAL 1:1COUNTY AGENCY CITY NAME STATE IP CODE T SITE PHONE N. WITH AREA CODE CA TYPE OF BUSINESS' ❑ y DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box It INDIAN EPA ID a 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER ESERVO❑ or ❑ TRUST N of TANK'S - LANDS AT THIS SITE EMERGENCY CONTACT PERSON (SECONDARY) EMERGENCY CONTACT PERSON (PRIMARY) DAYS NAME (LAST. FIRST) PHONE # WITH AREA CODE DAYS NAME (LAST. FIRSTI PHONE N WITH AREA CODE NIGHTS NAME (LAST FIRSTI PHONE N WITH AREA C DE NIGHTS NAME (LAST, FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFnRIIAATI1771A1 A- AnnOCCc — lami it,_T oo _T . III. TANK OWNER INFnRMATInN & AnnRFcc — tim is r or ^f%smn. NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODF PHONE N, WITH AREA CODE III. TANK OWNER INFnRMATInN & AnnRFcc — tim is r or ^f%smn. 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 COUNTY # JURISDICTION N AGENCY k FACILITY ID N N of TANKS at SITE L Ll 0 771 oT-o--]-�_ CURRENT LOCAL AGENCY F CILITY ID N APPROVED BY NAMEXn PHONE N WITH AREA CODE RMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N _FWPERVISOR-DISTRICT CODE — BUSINESS PLAN FILED DATE FILED _ YES ❑ NO ❑ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N , / By: t THIS FORM MUST BE ACCOMPANIED BY AT LEAST "' IR MORE TANK PERMIT FORM `B' APPLICATION(S), UNf THIS IS A CHANGE OF SITE INFORMATION ONLY, Z 10 IV NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ? ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY _ CITY NAME STATE ZIP CODE PHONE It. 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 COUNTY # JURISDICTION N AGENCY k FACILITY ID N N of TANKS at SITE L Ll 0 771 oT-o--]-�_ CURRENT LOCAL AGENCY F CILITY ID N APPROVED BY NAMEXn PHONE N WITH AREA CODE RMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N _FWPERVISOR-DISTRICT CODE — BUSINESS PLAN FILED DATE FILED _ YES ❑ NO ❑ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N , / By: t THIS FORM MUST BE ACCOMPANIED BY AT LEAST "' IR MORE TANK PERMIT FORM `B' APPLICATION(S), UNf THIS IS A CHANGE OF SITE INFORMATION ONLY, Z 10 IV