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CALIFORN WATER RESOURCES CONTR ARDP STATE OF FORM `A': UNDERGROUND STORAGE TANK PROGRAM ACILITY/SIT SIT E, INFORMATION and/or PERMIT APPLICATION C9 IF P. COMPLETE THIS FORM FOR EACH FACILITY/SITE 5 CHANGE OF INFORMATION 7 PERMANEN CLOSED SITE 1 NEW PERMIT � 3 RENEWAL PERMIT MA 'ONLY RIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE ONE ITEM � 2 INTE � 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE O A AS INFORMATION FACILITj�,SITE ME NSTGREET Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY .-..,.1 ❑ CORPORATION ❑ LOCAL-AGENCY F ERAL- ENCY ADD�� • I, �� ❑ INDIVIDUAL ❑ COUNtt-AGENCY N STATE ZIP CODE �� /T�� R'�� t'� ODE CITY No CA L7 v ✓Box if INDIAN EPA ID # #of TANK's T TYP BUSINESS: M p DISTRIBUTOR OCESSOR RESERVATION or ❑ A AT THIS SITE (J 1 GAS STATION D 3 FARM �/ r OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) !(\J p E ITH AREA CODE PHO E k WITH AREA CODE DAY$y.. LAST,FIRST) DAYS: NAME(LAST,FI T) PH E ITH AREA CODE p 0 #WITH AREA CODE NIGHTAME(LAST,FIRST) NIGHTS: NAME(LAST,FIR T) MUST BE COMPLETED) II. PROP RTY OWNER INFORMATION & ADDRESS - ( CARE OF A DRESS INFORMATION NAME C_ ) '"'....EE66..JJJJ��✓✓''�� ❑ STATE-AGENCY �•/ ✓Box to indicate ❑ PARTNERSHIP F DER -AGENCY MAIL orIS�TRE T RESS ❑ CORPORATION ❑ LOCAL-AGENCY STA INDIVIDUAL ❑ COUNTY-AGENCY ZI�O PHONE ,WITH AREA CODE aTv E III. TANK OWNER INFORMA ION & ADDRESS - (MUST BE COMPLETED) ��/ CARE F JDRESS INFORMATION NAME `C/1/ V �`' x to 74, ✓Boto indicate ❑ PARTNERSHIP ❑ STATE-AGENCY MAILING or S E ADDRESS [I CORPORATION ElLOCAL-AGENCY ❑ F RA -AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENC PHONE ITH AREA CODE STA5 ZIP GOD CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS C HECK ONE(1)BOX INDICATING WD FOR BOTH LEGAL NOTIFICATION AND BILLING: MCH ABOVE ADDRESS SHOULD BE USEI TRUE AND CORRECT. THIS FORM HAS BEEN COMPLETED UNDER PEN ALN OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,DGE,IS APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY�ID# # CO of TANKS at SITE JURISDICTION# AGENCY# o FN UNTY# � PHONE#WITH AREA CODE APPROVED BY NAME CURRENT LOCAL AGE CY FACILITY ID# O/Z ' - 2-s-, PERMIT EXPIRATION DATE PERMIT NUMBER PERMIT APPROVAL DATE BUSINESS PLAN FILED NO ❑ D %��{l� LOCA N CODE CENSUS TR # SUPERVI OR-DISTRICT CODE YES � c/ RECEIPT# Y' PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE CHE # 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 LY. ` p FARM A(3-2-88) �- \\\��' ..»tiff DATA PROCESSING COPY