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STATE OF CALIFORNble WATER RESOURCES CONTROwSOARD „ FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CZ-5 CHANGE OF INFORMATION ❑ 7 Y CLOSED SITE IJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) —4 FACILITY/SITENAMF �� CARE Of ADDRESS INFORMATION �r c kuwakm ADDRESS NEAREST CROSS STREET ✓Bo.Joir oort 0 PARTNERSHIP 0 STATE AGENCY / /(/10 {.�" AgCOAPOGAALION Cl COUNTY AGENIX ❑ FEDERAL CITY NAM l' 11�� STATE ZIP CODE _❑'1 SITE PHONE ft.WITH AR CODE mym CA 53 6 Zd9-W6- �60 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA IO R RESERVATION or of TANSY ❑ 1 GAS STATION E] 3 FARM El5 OTHER TRUST LANDS ❑ AAT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) , / PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE V 20 - 66-X60 qK�j NIGHTS NAME(IJ( ST) / PHONE p WITH AREA CODE NIGHTS. NAME(LAST FIRST) PHONE k WITH AREA CODE - S�r7- uK N II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION III u MAILIN 1 r STREET ADDRESS j ✓Box to intlicate Cl PARTNERSHIP Cl STATE-AGENCY Je C'Y� ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME ./ � STA ZIODE PHONE p� , 66AREA CODE ocl III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) 2 jI NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP ❑ STATEAGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERALAGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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-tV If. ❑ 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 k AGENCY R FACILITY ID M M of TANKS a11BITE ml I OOzoF3 1 10Oa0 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE Gf to PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 23,90 oZ VES NE] 19q CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M St: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1LOR MORE TANK PERMIT FORM 'B'APPLICATION(SI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. `\1JIII FORM A(3-2-88) DATA PROCESSING COPY Y't�