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STATE OF CALIFORNI? WATER RESOURCES CONTROBOARD f FORM `A': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE MINI , MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT HANGE OF INFORMATION 7 P NENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE s/ I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 10 FACILITY/ E AME CARE OFA RESS INFORMATION ADDRESS NEAREST CROSS STREET, Y�✓B vdieate ❑ PARTNERSHIP ❑LAGENCYOEAGENCT 00 A)• 10 U(�R (/vNt I] irypry CNAl10N � CON11 ANTY AGENCY fEGEMLAGENCf CITY NAME STATE P DE ITE PH E WITH AREA CODE Qom' CA S�LI �- 204 /- 940 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BOX if INDIAN EPA ID # I!T/1 GAS STATION 3 FARM 5 OTHER RESERVATION Or A AT THIS SITE U✓ ❑ ❑ TRUST LANDS ❑ /�D AT THIS SITE OV EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS ii: (LAS,T) V/ `4 ONE=WOIT'LAREA w DAYS�A OAST,FIRST) PH p WITH AREA CODE NI HTS FN ME(LAST,PRST) SPy0NE#WITH AREA CODE NIGHTS. NAA^(LAST,FIRST) pf�Oj{g#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) (/[` NAM CARE OF AQDFjESS INFORMATION MAIL ✓QpKIo Indicate 11PARTNERSHIP ElSTATE-AGENCY 7.lr ®"CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY MMM STAT5 ZIP CODE PHO E#,WITH AREA CODE SS Y/ CA 9g/os�s� _6 �l 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME_ J CARE XRESS INFORMATION MAILSNCypr T FT A'LDDDRRESS 'AV/ oxto indicate ❑ PARTNERSHIP 17 STATE-AGENCY J{ f� B CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME A STATE/4 ZIP CODE A PHONE ,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS SS `Y CHECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. yr II. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(POINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID# #of TANKS at SITE EEI 161 o J l 5 3 S Do 10 1 0 CURRENT LOCAL AGENCY FACILITY 70 N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER `,•([ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D E rILEP-1 n Z3• YES NO N11— CHECK# PERMIT AMOUNT SURCHARG AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1) MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON FORMA(3-2-88) DATA PROCESSING COPY