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STATE OF CALIFORNIA- WATER RESOURCES CONTROL-crOARD FORM IA': UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m: j 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE �`i,.a•"'� MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE rF"� ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE a I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) V FACILITY/SITE NAM� C4 CAREOFADDRESS INFORMATION ADDRESS /; NEAREST CROSS STREET b YlArab 0 LOCAL AGYP 0 SMTE-RAGEN !/1/ �/ GDRPIXtAiION ❑ 10G1 P.GGEN ❑ R➢ER/l-AGENCY ❑ INDVIWK ❑ WGNIYAGENCY CITY NAME S �N STATCA ZIOOF SITEPHONE D� TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4,10II&ESSOR ✓Box if INDIAN EPA IDN S If ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION or #W TANKY ❑ TRUST LANDS ❑ AT THIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: ME(ST.FIRST) PHONE N W�M AREA CODE DAYS: NAME(US,FIRSTJ PHONE#WITH AREA CODE S NIGHTS: NAME(LAST.FI ) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIBSST) PHONE#WITH AREA CODE C ✓V 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME _ CARE OF ADDRESS INFORMATION 0 /✓� �� /✓�/ ( - LSV' I MAILING or STREETADDRESS ox to indicate 0 PARTNERSHIP 0 STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY 11 FEDERAL-AGENCY G eese x 0 INDIVIDUAL 0 COUNTY-AGENCY CIN NAME SvvSTATE, - ZIP CODE (� PHONEN,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) J �f/ NAME n CARE OF ADDRESS INFORMATION V MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 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)BOK INDICATING WHICH ABOVE ADDRBSB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. P, 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 If SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCYII FACILITY ID If If of TANKS at SITE CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE#WITH AREA CODE Alam te,-L 3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \ LOCATION CODE CENSUS CTM SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED D ,406*� 1Zti YES ❑ NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY; _F THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FORM A(3-2-88) "'^' DATA PROCESSING COPY