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STATE OF CALIFORNIA~ WATER RESOURCES CONTROttOARD zf `""` l` FORM A: UNDERGROUND STORAGE TANK PROGRAMa SITE �i FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l L / COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY JKNEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE FJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O/ I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FAC SITE NAME D n� � CARE OFA�RESS INFORMATION ADDRESS((-�T S NEA/R1E,//TCROS$STREET ✓gw biMink ❑ PARTNERSHIP ❑ STATE AGENCY S • � .1y,1( t9'ccXRPoaeno, ❑ (OCA(-AGBUY ❑ FEDERAL-AGENCY ❑ INWDUu D D)UNTr-AGENCY CITY NAME STATE ZIP E ITE PHO E If WITH AREA CODE L 06 i CA / �! 33 -zz13 TYPE OF BUSINESS: ❑ 2 DISTRIBUIOR ❑ 4.PROCESSOR ✓Box H INDIAN EPA ID/-,/)A X/ X of TANK's RESE ❑ 1 GASSTATIGN ❑ 3 FARM �5 OTHER TRUSTVATION LANDS of E] r ICY AT THIS SITE 01 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) X WITH AREA CODE /I 1 ag- 7/Z 7 r P`/(HO AAE y a 'Q r/ 'J NIGHTS: NAMEVI-AST.,11ilRO (` PHONE X WITH AREA CODE NIGHTS. ,NAME(LAST,FIRST) 0A NE X WITH AREA CODE Y d 9/4 II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) ry .L� CARE OF ADDRESS INFORMATION EDI.( MAILING STREET ADDRESS /�� ✓Box to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY EDE L-AGENCY D INDIVIDUAL DCOUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 06 CX 1 9s�1/0 III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAMEkAt CARE OF DDRESS INFORMATION 0 rti( Q MAILING or STR ADDRESS ��x to indicate D PARTNERSHIP D STATE-AGENCY O CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY �, D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N. ITH AREA GODE LSD i CA SSZu� L)9 33S- -Z-Z-33 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. ❑ 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 R JURISDICTION If AGENCY S FACILITY ID Of X of TANKS at SITE ED 6 d / = I zo D d 11 CURRENT LOCAL AGENCY CILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE p '2J /6 PERMIT NUMBER PERMIT APPROVAL DA c ( PE MIT E PIRATION DATE /& ki LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED D�I rJ 7, Flo YES Fl NO CHECK X PERMIT AMOUNT SURCHARGE JUNINT FEE CODE RECEIPT X B xx \ 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 '•,\ FORM A(3-2-88) DATA PROCESSING COPY �/