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STATE OF CALIFORNIO WATER RESOURCES CONTRAOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•oa�" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT Ee6 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) —/ FACILITY/SITE Nrl CARE OF ADDRESS INFORMATION I/V F" N� S AF/zo < vice ADDRESS //_ /�Ap/J NEAREST CROSS STREET rdraw ❑ PARRIBffiRP ❑ STATEAGENLY b 2 so U/'V d ke 5 f'ftD"5 TION 0 CW4TY-AGEN FEDERAL MM I#GNDUAL ❑ caATTacPna CITY NAME v STATE ZIP CODE SITE PHONE#,WITH AREA CODE 5?G6'k"-r _ CA 6 — 9al9 TYPE OF BUSINESS: ❑ 3 DISTRIBUTOR F-14 PROCESSOR ✓RW B INDIAN EPA ID ReTIONN ❑ IT of TANK's 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS of ElAT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAY : NAME(LAST,FIRST) PHONE p WITH AREA CODE Coe e NIG S: NAME(LAST,F19&T) PHONE N WITH AREA CODE NIGHTS: NAME(LAST, IRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION np,IV �s ,Aeo ce MAILING or STREET ApDRESS�� -i�lo(be S to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY //YVJJ_.Z- CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME rn 7 �� `" 5 ��o ��V1 CARE OF ADDRESS INFORMATION MAILING or STREET;C �l ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY F(F(//,� ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL C COUNTY-AGENCY CITY NAME57o 'I STAT[f- ZIP CODE PHONE H AREA CO) O O IV. LEGAL NOTIFICATION AND BILLING ADDRESS S/nN/ 2 CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. Z 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 N AGENCY R FACILITY ID# It of TANKS at SITE m = = 1010111C Y o 1 1 01 v 10 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE R WITH AREA CODE �J ','- � v PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS iiIACTM D SUPERVISOR-DISTRICT CODE BUSINESS PLAN NFILED NO DATE FILED 2 `$ w ❑ ❑ CHECKk PERMIT AMO NT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: sA TMS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(34-118) • .