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STATE OF CALIFORNIPe WATER RESOURCES CONTRO"OARD a FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EM 5 CHANGE OF INFORMATION ❑ 7 EMM&UWTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q I. FACILITY/SITE INFORMATION & ADDRESS— (MUST E COMPLETED) co FACILITYISITE NAME 'I'v yJ CARE OF ADDRESS INFORMATION L /h M Gvw SSTREET ✓50x1(Ydisk ElPAWNERAIIP ❑ STATE AGENCY ADDRESS NEAREST CR Q QQ S, III" O Q 7 �iUeR AQC ip7RPOMNIBN camry cFNL 11 HBBu Acwc CITU NAME JO - /i�O STATE ZIP CODS�zo� SITE PH —WITH AR-4C z TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR 4 V/IE`SSD.R ✓Box if INDIAN EPA ID a �7/ If of TANK's ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUSRESET LANDS ATION or ❑ AT THIS SITE 6 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE �' ';:lo —' NIGHTS: NAME(LAT,FIRSV PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE Sot_ll� 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME /�� VOa �u AI� / CAPE OF ADDRESS INFORMATION ES MAILING or STREET ADDRESS ✓Box to iodicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl INDIVIDUAL COUNT AG NC ION ElFEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE 1.WITH AREA CODE d cyos✓ 9 Seo Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑-� P��PI�PNERSHIP ❑ STATE-AGENOY ❑ CORPORATION 6VOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL TJ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE x.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. ❑ 11. ❑ 111.❑ 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 COUNTY11 JURISDICTION R AGENCY R FACILITY ID N ( N o1 TANKS at SITE C) 10 1 C71 0 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE 570 4TV G4 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION M# FMRMff NSUS TR CT N _l SUPERVISOR-DISTRICT CT CODE BUSINESS PLAN FILED DATE FILED YES NO AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: 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-e8) �� DATA PROCESSING COPY