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.,,-, J000 STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD u �o Z FORM 'A" UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION/3 0, Ic COMPLETE THIS FORM FOR EACH FACILITY/SITE 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE 1 NEW PERMIT � 3 RENEWAL PERMIT �? � MARK ONLY F y AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ONE ITEM D 2 INTERIM PERMIT El I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION FACILITY/SITE NAME e/na~ Lr/' ukj PARTNERSHIP [I STATE-A NEAREST CROSS STREET ❑ TION ❑ lSCI1AGENp ❑ -AGENCY ADDRESS ADDRESS (y/�/ IC /r ' �j INGNIGWL C] COUNTY AGENCY O C/ ZIP CODE SITE PHONE#, H AREA CODE STATE h //L-- CITY NAME ,/ • CA c- 3 (�f/1 F� en fJ EPA ID a N of TANK' O / TYPE OF SUSINESS'. 2 RIS OR 4 PROCESSOR ✓Box iATIONINDIAN / ' /i AT THIS SITE RESERVATION WIt, I GAS STATION 3 FARM 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(SECONDARo'E a wITH AREA coDE EMERGENCY CONTACT PERSON [PRIMARY)HONE a wITH RHEA CODE DAYS: NAME fust HRSTI DAYS. NAME(IAST,FIRST) FA CODE {T_ PHONE a wITH AR s /' PHONE p WITH AREA CODE NIGHTS: NAME(LAST.FIRST) NIGHTS NAME(LAST.FIRST) �/ PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME 0 STATE-AGENCY ✓Sox - tlicare ❑ PARTNERSHIP ❑ FEDERAL-AGENCY MAILING ar STREET ADDRESS ❑ FOR ION ❑ LOCAL AGENCY INDIVIDUAL ❑ COUNTY-AGENCYPHONE p,WITH AREA CODE STATE ZIP CODE CITY NAME TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPDL ETED)ADRESS DN NAME / /a ✓Sox r are ❑ PARTNERSHIP Cl STATE-AGENCY MAILING or STREET ADDRESS ❑ PORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTV-AGENG PHONE N,WITH AREA CODE STATE ZIP CODE CIN NAME LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 10110❑ III. I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CO==RRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) CAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY M FACILITY ID K N of TANKS at SITE 3 q / 1 v I v RRENT LOCAL AG CY F ILITY APPROVED BY NAME PHONE N WITH AREA CODE I C�ID# 1 RMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ATION CODE CEN�83TRaA�N SUPERVISOR-DISTRICT CODE BUSINESS PSN❑FILED NG ❑ DATE FILED �_v ECKN /y PERMIT AMOUNT SURCHAARRGr`EIIAMOUNT FEE CODE RECEIPT# (/OBY: 0 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. b(3-2-88) DATA PROCESSING COPY