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STATE OF CALIFORNIR WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION /L� COMPLETE THIS FORM FOR EACH FACILITY/SITE .oe�`• MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE 0 SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAMECARE OF ADDRESS INFORMATION m LC7z CJJ ADDRESS NEAREST CROSS STREET ✓Bo m ❑ PARTNERSHIP ❑ STATE AGENCY (/ — ❑ MTCN ❑ LOCAL AGENCY Cl FEDERAL �' /'�e�r"�v �- INDIVIDU, ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE % ori !v CA 9Sb�lc �av9J 7,y -d?s1 TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 P SSOfl ✓Rox II INDIAN EPA ID N RESERVATION or M at TANK'N ❑ 1 GAS STATION ❑ 3 FARM 50THER TRUST LANDS ❑ cls Coo O/ k- Ova AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE S//p 'S/1-/ NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME PSTT,FIRST) PHONE N WITH AREA CODE s/1 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME C CARE OF ADDRESS INFORMATION J MAILING or STREET ADDRESS ✓Bax Lo indicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 5 MAILING or STREET ADDRESS ✓Box to indicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ 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. 1L ❑ 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY R FACILITY ID X R of TANKS at SITE = L3-k)- 171 = laloll lr 3 UIEEololol CURRENT LOCAL AGENCY FACILITY 10 t APPROVED BY NAME PHONE N WITH AREA CODE G DlkE,? 2(�, 1 06 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LHECK# ODE CENSUTS TRACCT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED I']� DATE FILED / YES 0 NO ' / O1/3( &1- PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X BY: (n 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) Cl -r/ 0 DATA PROCESSING COPY • /