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STATE OF CALIFORNIA WATER RESOURCES CONTROL bARD „ FORM A: UNDERGROUND STORAGE TANK PROGRAM SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY LOSED SITE ONE ITEM E]2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) FACILITY/SITE NAME _ CARE OF ADDRESS INFORMATION /!tD ADDRESS — NEAREST CR"-OSS/S"-STREET ✓Bwwk*w ❑ PAAfIIESAP ❑ STATE MM ❑ mwm*L ❑ cGNrY.Ati cY ❑ �muACDK CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA 95do-5-- -v - TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Bax B INDIAN EPA ID a IT W TANK's ❑1 GAS STATION ❑3 FARM ❑ RESERVATION or ❑ AT THIS BITE 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE F WITH AREA CODE G.� NIGHTS: NAME(LAST,FIRM PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FlRST) PHONE k WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME 4J _ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP - ❑ STATE-AGENCY ❑ TION 13LOCAL-AGENCY ❑ FEDERAL-AGENCY DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE CA 9Yactf III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to mmeate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CRY NAME STATE ZIP CODE PHONE M,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS _c NECK 011E(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD MUSED FOR SOTII LEGAL NOTIFICATION AND BILLING: I. ❑ IL RI.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY V JURISDICTION If AGENCY M FACILITY ID R V of TANKS at SITE " 310 1 0 -'2 3 8 v d o o c7 CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE F WITH AMA CODE A PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE E DE CENSUS TRACT F SUPERVISOR-0IBTRICT CODE BUSINESS PLAN FILED DATE FILED 2 303 YES NO 0 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 0 BY: V� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK Pow FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FO M A(3-2-135)