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I, STATE LIFORNIA WATER RESOURCES CONTROL BOARD FORM `A'. T UNDERGROUND STORAGE TANK PROGRAM V " �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT L . CHANGE OF INFORMATION 1 PER CLOSED ONE ITEM ❑Z INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6/ I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FAC16jW/SITEN E N CARE OF DRESS INFORMATION ADDRESS - NE NW ST CROSS ET ✓ b edict@ ❑ PARTNMW ❑ STATE-AGENCY 77 /�L fAAPoMLIN 13 LGUNTY-ANC EDER, AGENC ❑ INDIVIDUAL ❑ CWNflAGENC/ CITY NAME STATE Z SITE PHINE#,WITH Y RCOD CA Mx Yob TYPE OF BUSINESS: SMIBUTOR ❑ 4 PROGES60R RI 10 i11NDIAN EPA ID # RESERVATION or t l #oITANK's ❑1 GAB STATION 3 FARM ❑5 OTHER TRUST LANDS ❑ /� ATTHISSRE a EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA (LAST,FIR PHONE#WITH AR CODE DAYS: NAME(LAST,FIRST) PH NE p WITH AREA CODE ' P A NIGHTS: NAME( T,CRST) PHONE#WITH AR CODE NIG NAME(LAST,FIRST) PH NE#WITH AREA CODE rb s ?Z? SYf. � SA " S II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE 05 PDDRESS INFORMATION h MAI or ST ADDRESS ✓ zto indicate 0 PARTNERSHIP 0 STATE-AGENCY 1�AJM/�n Ay I CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY `VN ##/` �l� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME CAA&t STATE ZIP QPUF. PHONE ,WIT AREACODE III. TANK OWNEFVINFORMATION & ADDRESS - (MUST BE COMPLETED) 7 NAME CARE OF ADDRESS INFORMATION MAILING 6,STREET ADDRESS ✓Boz toindkate ❑ PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE It,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. ❑ 11. 6e, 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE J LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It AGENCY# FACILITY ID# #of TANKS at SITE M I o 1 00 0 & CURRENT/LOC�ENCY FACILITY ID# APPROVED BY N 7 PHONE#WITH AREA CODE V / 1W PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCATIONODE SUSTRACT# SUPERVI -DISTRICT CODE BUSINESS PLAN FILED YES NOe/MRIMIT'RINKII SURCHARGE AMOUNT FEE CODE RECEIPT M 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-SS) `�. DATA PROCESSING COPY