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STATE OF CALIFORNIA- WATER RESOURCESCONTROL-IDARD 5e """ FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONPE/RMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE TI I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/ E NAME CARE OF ADDRESS INFORMATION 4 ADDRESS NEAREST CROSS STREET ✓BwbfdraV D PARTNERSHIP D STATE AGENCY as i �. Aff If ElH[ I oLG�� ° CITY NAME STATE ZIP DF„. SITE PNO p,WITH AFE=CODE C CA WSJ (POa S3 TYPE OF BUSINESS. ❑2 DISTRIB R ❑ 4 PROCESSOR -/Box if INDIAN EPA ID N /V v /"� ❑ N W TANSY rj'1 ❑ 1 GAS STATION FARM ❑ RESERVATION or 5 OTHER TRUST LANDS AT THIS SITE (� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE V WITH AREA CODE (9p Cw -T l (^0-1611 ,3�00-- NIGHTS: NAME(LAST,FIRV) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME /��Q /e/� 1 �. CARE OF ADDRESS INFORMATION MAILING or STgEET ADDRESS /l•J� •Ji-•IL ✓Box to indicate 1:1 PARTNERSHIP D STATE-AGENCY /t_� Cl CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY 3 D INDIVIDUAL D COUNTY-AGENCY CITY NAMESTALE/9 ZIP OD P a0ONE*� .y��DE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Cc S MAILING or STREET ADDRESS ✓Box toindicate D PARTNERSHIP D STATE-AGENCY ' ❑ CORPORATION D LOCAL-AGENCY ❑ FED RAL-AGENCY i D INDIVIDUAL D 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 ADDIMBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. HL❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION N AGENCY R FACILITY ID S R of TANKS at SITE m [ZD16 10 1 L�1 / CURRENTLO AL AGENCY FACILITY IDN APPROVED BY NAME PHONE F WITH AREA CODE PERMIT N MBR PERMIT APPROVAL DATE PPERMffIRATION DATE LOCATIO CODE CENSUS TRACTM SUPERVISOR-018TRICT CODE LAN FILED DAT FILED 3 ] S NO [CHECK♦ PERMIT AMOUNT 1 SURCHARGE AMOUNT FEE CODE RECEIPT It BY: IIIIIi THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPUCAT.ON(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-SB)