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STATE OF CALIFORNIP WATER RESOURCES CONTROROARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE,('' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o �w COMPLETE THIS FORM FOR EACH FACILITY/SITE "'•J "�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE IJ ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 51..1 CD 0 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N FACILITY/SITE NAME CAREOFADgRSSS INFORMATION ,^^�� vQR Mae in ADDRESS hh//��/I�� v1 NEAREST CROSS STRE ✓ rale 0 PARTNERSHIP D STATE AGENCY A/(TV Union e{� D INDry OAALIDN 0 ClJCl DUN1Y-AGENCY AGENCY 0 FEDERAL AGENCY CITY NAME I vck+o� STATE ZIPJ;,pD€ �� SITE PHONE p,WITH AREA CODE t4(64 9 ` TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOfl ✓Box it INDIAN EPA ID p (_]I S 2(�\J RESERVATION or -'� X of TANK's ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE eek an v NIGHTS: NAME(LAST,FI T) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) ��- PHONE k WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION RCIE K MAILING or STREET A DRESS I/Box to intlicate ❑ PARTNERSHIP 0 STATE AGENCY 3U2'� Sn 0 CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY `-.l %R INDIVIDUAL 0 COUNTY-AGENCY CITY NAMES k STAT ZlpgODE 0 PHONE A,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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. ❑ H. EZ 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 N FACILITY ID N At of TANKS at SITE E9 16 1 191910 0 CURRENT LOCAL AG N Y FACILITY ID# APPROVED BY NAME PHONE*WITH AREA CODE LLE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M3 CIL." UPERVIS •I ISTRI TCO BUSINESY PLAN FI� DATE FILEO NO ❑ FILED 1 ^� CHECK* PERMIT AMOUNT SUR RGE AMOUNT FEE CODE RECEIPT# BY: 40 THIS FORM MUST BE ACCOMPANIED BY AT LEAST I�MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, RM A(3-2-BB) 0 DATA PROCESSING COPY