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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD sE ' FORM `A': UNDERGROUND STORAGE TANK PROGRAM SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION " G COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE14— 5 41 z I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) L!1 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS �" NEAREST CROSS STREET ✓Bm loiMink 11PASTNDGIIP ❑ STKrE AGRICY Q�"�i Yt WetJ. lic'r� ❑ DOWORATM 1:1uxAt-AGEN9 ❑ FmDwi AGDO Y 11INDIVIDIIAI ❑ CDUNIYAGMGY CITY NAME G STATE CZIP CODE SI D . CODE A A TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box 4INDIAN EPA ID # ❑ IGAS STATION ❑3FARM <OTNER TRUSTTLANIDS ON or ❑ �" � -- AT THIS SITE D EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Gl ey) n . Re-o c , Cao4 45-593 e1 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE S02rA 'e, II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sam1e as MAILING or STREET ADDRESS ✓Boz to inoicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sck », `e QS S MAILING or STREET ADDRESS ✓Boz to inoicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. �Z IL ❑ 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# JURISDICTION It AGENCY# FACILITY ID# It of TANKS at SITE 3 9 d 10 1 iE010101 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENBUB fli.CTN SUPERVISOR-STRICT CODE BUSINESS P$NFILED No El DATE FILED1011' t. on,3 15 1 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT j(jy 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 ONLY. FORMA(&2-88) ---- DATA PROCESSING COPY �—L