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STATE OF CALIFORNIP WATER RESOURCES CONTROAOARD I5f '"" , , a ` . z FORM A: UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE "'FOR—"_ MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ERIPERMANENTLY CLOSED SITE —4 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 FACILITY/ ENAME CARE OF ADDRESS INF MATION JIL G S�ro1 0(_-I, teabu ADDRESS I NEAREST CROSS STREE ✓Bw to vNrale ❑ PARTNERSHIP ❑ STATE lW�t I n �l� r 1 n � ❑ CgRPIDFAFN Cl LOCALAGENCY ❑CY MLI Ar NLY CITY NAME 5 11x, STATE ZIP C9��O� ,)TEBq CM,WITH AREA`D1 TYPE OF BUSINESS: FL EPA ID # (lJ'(„{l(-jl Cl (I) ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR Boz if INDIAN Mot TANK', RESERVATION or ❑ ATTHISSITE I GAS Is [:] 3 FARM OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA COOS NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION e) CV'nnc MAILING or STR TADDRESS ✓Box to indicate 11 PARTNERSHIP ❑ STATEAGENCY �(R,�a, y C El CORPORATION [ILOCAL-AGENCY ClFEDERAL-AGENCY V� X ❑ INDIVIDUAL ❑ COUNTY-AGENCY P.r' CITY NAME STAT1E ZIP CODE PHONE li,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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. WK❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION a AGENCY M FACILITY ID a a of TANKS at SITE CURRENT LOCAL AGENCY FACILITY 10 aL� 1 APPROVED BY NAME PHONE a WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LC.E IONC�E CENSUSTRACTa SUPERVISOR-DISTNICTT CODE BUSINES,P SN FILED NG ❑ DA� F�� %� l* PERMITAMOUNT SURCHARGE AMO^OU1UNNT FEE CODE RECEIPT* 1r BY: /,-C/1 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 46