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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION S COMPLETE THIS FORM FOR EAC AGILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S� I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACWTY/81TE NAME I CARE OF ADOR S INFORMATION N ( Su Dor— ADDRESS NEAREST CROSS ST ET 0,00ple 11PARTNERSHIP ElSTATE AGENCY VOD 6- k 11 me WAAL NoN ❑ Imrm AGENCY El LomAGENcY ElFEDERALAGEN Y CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE T CA s 76 - TYPE OF BUSI SS: F__] 2 DISTRIBUTOR ❑ 1 PROCESSOR ✓BOX If INDIAN EPA ID k ❑ ❑ ❑ TRUST LANDS or ❑ N a TANSY I GAS STATION 3 FARM 5 OTHER AT TNIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST, IRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE W V - y6 -e6oLl NIG TS NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE molbi W V u'"'p— II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION / N e 1 oC MAILING or STREET ADDRESS ✓Box to indicate ElPARTNERSHIP ❑ STATE-AGENCY CC Ov+ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY\ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NA STATE ZIP CODE PHONE N,WITH AREA CODE �oc(� G4.! CA 1 qS206 -&Qf III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME [��y�� as CARE OF ADDRESS INFORMATION ✓F71! "L� MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ 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 M JURISDICTION N AGENCY M FACILITY IDM M of TANKS M SITE " 3 = = 10101 -2_T0TEE01> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT AFPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ;23 3 2 YES NO 7 n �? ZL CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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 ONL . FORM A(3-2-88)