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J 1 A 1 t OF CALIFORNIA WATER RESOURCES CONTROL 'OARD FORM A : SITE UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, Y/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE rd IC MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT ONE ITEM 2 5 CHANGE OF INFORMATION MANENTLY CLOSED SITE/ f"L � d AMINTERIM PERMIT ENDED PERMIT 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) cc FACILI ITE NAME CT ILr r 1 O`. q PR CARE OF ESS INFORMATION ADD lYl(In .. y C NEAREST CROSS STR ET ✓ 13PgAiNFFBIP � 4giE NGEKK,Y Ql• vZ u� CONPOMTIpN 0 LOCk AGECY 0 E®EVI,NGENOY CITY NAM 0 INONIWµ 0 CDIHiY-NGENLY , STATE Z CODE 1h� SITE PHONE N.WITH AREA CODE � / TYPE OF BUSINESS: ❑ 2 DISTRIBUTOfl d PROCESSOfl ✓Box it INDIAN EPA o A V 01 O '- (0 q yL/y 1 GAS STATION 3 FARM p' RESERVATION or TRUST LANDS ❑ N of TANK, AT THIS SITE /Vl EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS. NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST �" I PHONE N WITH AREA CODE OMIT rySU� �20 ( 2`1`6 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(I-AST,FIRST PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to,racate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY ClMOWIDUAL 0 COUNTY-AGENCY CITU NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING a STREET ADDRESS ✓Bax to,roicate Cl PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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. 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(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION A AGENCY* FACILITY ID M M of TANKS at SITE 010 1 ( JZo I O 10 1 CURRENT LOCAL AGENCY FACILITY 10 M APPgOVE4 BY NAME PHONE x WITH AREA CODE X11 o m � 2-a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIjy1CQDE C�SUSRACTa BUPERVISOR-0I ICTOCODE BUSINESS PIAN FILED D FIL r\-\J I /�('- VES NO CHECK♦ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BYvjg ITHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS ISA CHANGE OF SHE INFORMATI ORM A(3-2-88) DATA PROCESSING COPY