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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® : IZO I COMPLETE THIS FORM FOR EACH FACILITY/SITE [;ARKONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F+ ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N 1. FACILITY/SITE INFORMATION S ADDRESS-(MUST BE COMPLETED) OD 1 FACILITY/SITE N E CA F ADDRESS INFORMATION 1 a e�a J ADDRESS NEAREST CRI STREET ✓Bmb.** ❑ PANINERSHW 0 STATE AGI 0 BATON ❑ LOCAL#SENGY 0 FMEM AORILY VO CF1 Domdu uto 0 INOMOUAL 0 00woY EAcT CITY NAM STATE ZIECODE SITE PHONE If,WITH AREA CODE 1 CA a 10 ' TYPE Of BUSINESS: ❑ p DISTRIBUTOR ❑ A PROCESSOR Box if INDIAN EPA ID # #a1 TANK'# , ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHFA RESERVATION �r ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) n^"Q' NAME(LAST,FIRST) PHNE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE m-mm sal z 9-2-fSg2 NIGHTS: NAME(LAST,FIRST) P NE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE e S� g2-►s II. PROPERTY OWNER INFOR ATION & ADDRESS - (MUST BE COMPLETED) NAME CA WF ADDRESS INFORMATIONS {r LL/6- MAILING orSTR TADDRESS /BoxtIfindmale 0 PARTNERSHIP 0 STATE-AGENCY 2n 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY . INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE sz 20 - �- 111. TANK OWNER INFOR ATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ur 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# JURISDICTION# AGENCY# FACILITY ID If It of TANKS at SITE 10101 '2- 12=- a6 VRMIT AL AGENCYFACILITY ID# APPROVED BY"ME PHONE#WITH AREA CODE R PERMR VAL DATE PERMIT EXPIRATION DATE A LOCATIOWCODIE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE RILED. 43 ,4SO Z YES [:] NO 1� 1 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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(3-2-68) - � DATA PROCESSING COPY --r