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STATE OF CALIFORNIA' WATER RESOURCES CONTROL'WOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 54 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED S1TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE cj I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION cJxj NitJim r )er ADDRESS NEAREST CROSS STR T ✓�mbiH¢te ❑ PSN Elw ❑ STATE AGFNLI' n .y �" N FMNpP TION ❑ LOGLASIRCY ❑ FIMMASE10 /OSO Soo. U .�Y 21 ' S'/" ❑ uDmmuL ❑ =ATY AGEND CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE S-foc L4& CA CA 1 '75.2 _#67-61000 TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR /PROCESSOR ✓Boz i11NDIAN EPA IDp _ N o1 TANK'a RESERVATION ❑ �^ 5 ❑ 1 GAS STATION o1 ATTHISSREON ❑ 3 FARM ❑ S OTHER TRUST LANDS /7 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE M WITH AREA CODE mer Lj/rn tar -000 NIGHTS: N E(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMEI CARE OF.ADORESS INFORMATION /'yam/AMq, Grower ,vet' MAILING or STREET ADDRESS ✓.fox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY O YI CORPORATION DLOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 0,WITH AREA CODE C.4 95.20/ 709- _4000 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION QS MAILING or STREET ADDRESS ✓Sox loindicale 0 PARTNERSHIP D 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)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 NA E PRINTED 6 SIGNATURE) DATE ,$ D9- A w-0,;jq?7.z LOCAL AGENCY USE ONLY COUNTY K JURISDICTION E AGENCY E FACILITY YIID B B of TANKS BI SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE 0 WITH AREA CODE DWA010 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS"ACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / r1 3 O YES NOE3 a!� 9 CHECK Y l PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y BY: e 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(3-2-8B)