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..-.,.a'.�ror•.-,t:^.r.,:nrny..-y...rtr..: .. v. ..a,.. - � n sz. STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD f 1 ffi �m FORM A: UNDERGROUND STORAGE TANK PROGRAM �a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE ONEN.TEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ?16 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION -mic-Yolo c.K ry ADDRESS NEAREST CROSS STREET ✓ xtoiMvale ❑ PNRNEB&P ❑ STATE AGENCY CORPORATION ❑ LOCAL AGENCY Cl FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME o STATE ZIP kZV 6 SITEPHONE p.WITH ATEA COD��/ �I S-r TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PFrOCESSOR ✓Box if INDIAN EPA ID# •o1 TAAN•KQK''t RESERVATION or AT THIS SITE ❑ f GAS STATION 03FARM 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST.FIRST PHOJI.E N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMP ETED) NAME CARE OF ADDRESS INFORMATION a S 5 C MAILING or STRP ADDRESS xlc jrtlUATte ❑ PARTNERSHIP ❑ STATE-AGENCY 20 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY V INDIVIDUAL ❑ COUNTY-AGENCY CITYNAME 1 STATE ZIPCO / goPHONE WITH AREA COBE,,' III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) 66 NAME _/ � � � /i CARE OF ADDRESS INFORMATION MAILING or STR ET ADDRESS `/+/y/e• ✓ ox to•(}indcatee^V E- ❑ PARTNERSHIP 0 STATAGENCY �/I CORPORATION ❑ LOCAL-AGENCY 13FEDERAL-AGENCY Q N B y O 1 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME / STATE ZIP CO,Z4 PH p,WITH AR�CQB/�� IV. LEGAL NOTIFICATION AND BILLING ADDRESS 9 6 CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ Il. ❑ 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY41 JURISDICTION If AGENCY# FACILITY ID N M of TANKS NI SITE do UpG 13 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY ME PHONE N WITH AREA CODE 5703 W PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 7-2 J- 8." LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 01 2 P -?-IVN YES E] NO 7.i� _ IT CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE TANK PERMIT FORM 'B' APPLICATION(S),UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-881 /^ I DATA PROCESSING COPY Y