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STATE OF CALIFORM7r' WATER RESOURCES CONTR &4OARD FORM A: UNDERGROUND STORAGE TANK PROGRAM , SITE �/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z �/ �y COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY [L2"I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F'a ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE IV I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME /,� CARE OF A DRESS INFORMATION A SToa�� of /tOA AD ESS AREST CROSS STREET ✓RwbYxFraa ❑ PARTNERSHIP El STATE AGEM7r �BS/ E Yet L;Pe /2sa1 o a ORuTNxi o �AGENCY CITU NAME STATE ZIP E 2W O ITE PHO p,WITH AR TYPE F BUSINESS: ❑2 DISTRiBUTDR ❑ 4 PROCESSOR ✓Box it INDIAN EPA IIDJ•N !`]E SS y 1 TYPE STATION ❑3 FARM ❑ 5 OTHER TRUSTYATION IANDS or ❑ ID AT THIS SITE 02j EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) S. NA (LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME �(LAST.FIRST) PHONE 0 WITH AREA CODE SA NIGHTSIN ME(LAST, RST) PHONE#WITH AREA CODE NIGHTS AME(LAST,FIRST) PHONE R ITH AREA CODE S ,a Y-03D9 v � 4 II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAIL _ _ // �� CARE O ADDRESS INFORMATION MAILWGor//STTR/E-ET ADD4�a/Sv ✓0ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 11CORPORATION ❑ LOCAL-AGENCY FEDER -AG NCY IJ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY—m 04A NAM c STATE 21P lir 6 PHONE (TH E;CODE )3 III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) l L 'SSA Q CARE OF ADDRESS INFORMATION " MAILING or STREET ADDRESS- ✓Be.tc intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. II. ❑ 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 N JURISDICTION MAGENCY R FACILITY ID R R of TANKS at SITE I 1010 1 1 a 10 10 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAM PHONE R WITH AREA CODE ✓� svy Q PERMIT NUM ER PERMIT APPROVAL DDAT�ET PERMIT EXPIRATION DATE LN LOCATION CODE CENSUSACCTT N SUPE VISOR (STRICT CODE BUSINESS PUN FILED NO / DATE FILED CHECKN PERMIT AIMJ§OUNT SURCHLAGiE AM UM FEE CODE RECEIPTM IT—aT/ BY.. THIS 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 0 Y FORM A(3-2-88) �� DATA PROCESSING COPY *=gB