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STATE OF CALIFORNIX WATER RESOURCES CONTROt BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �_o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 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 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME ` CARE OF ADDRESS INFORMATION ADDRESS / r NEAREST CROSS STREET ✓BN W WM D PISRIBDW D STATE4SSILY /1O � F-T ' - " (, I,Y D MMWIL D 0011YASRD EOFN AGRp CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE S TbG/`�OY I CA q l�Zv TYPE OF BUSINESS: E]y DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N RESERVATION /- �/ Bal TANK'S ❑ 1 GAS STATION ❑3 FARM 2r5 OTHER TRUST LANDS ❑ V AT THIS SITE 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 gR ToPm 2,�rqW- yoR (Ae 7DAl (zL)e-1146 - 0 NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION CSL K �RoPE,2T)6 MAILING ar STREET ADDRESS ✓Box to iwwale D PARTNERSHIP D STATE-AGENCY Q 2 ] ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY / D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP COHONE N,WITH EA CODE fAa F,24 /5C ?7//q III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAIUNGor STTCF�TADDRESS - _ ✓Box W iM¢ale D PARTNERSHIP D STATE-AGENCY fJO /]Q D CORPORATION D LOCAL-AGENCY D FEDERALAGENCY .L V D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE r�N Ck Q�Zo ' y6( - yv43 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDMM SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS"ME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION R AGENCY N FACILITY ID N N of TANKS at SITE o 16 12-E= lo 149 1 o CURRENT L AL rNCYF````AOILITY1DaRE � APPROVED BY NAME PHONE F WITH AA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FMD Q y YES NO ❑ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• eY:c `fay � (Al. 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. '_