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STATE OF CALIFORNIO WATER RESOURCES CONTROINIOARD FORM'A': UNDERGROUND STORAGE TANK PROGRAM = " SITE �FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION J (' 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Z>-6HANGE OF INFORMATION ❑ 7 PER�MANEN�TLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT F-14 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE /t 'l7 l I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME JURISDICTION IF CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION MCIYN+ffretS14 I MAILING or STREET ADDRESS ADDRESS CITY NAME NEAREST CROSS STREET ✓davl 1& ❑ PARTNERSHIP ❑ STATE AGENCY (09 O I= a L— ' '� !l d1J f `��/ C) POR4IION ❑ LOCAL AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE STATE ZIP CODE v1 ' SITE PHONE N. WITH AREA CODE LOCATION CODE CA G533 BUSINESS PLAN FILED 8 i'M TYPE OF BUSINESS: ❑ p DISTRIBUTOR [—] 4 P OCESSOR ✓ Bax if INDIAN EPA ID ft YES ❑ NO ❑I GAS STATION 3 FARM ❑ 5 OTHER RESERVATION or TRUST LANDS ❑ / ^ ' Iv � q of TANK'a AT THIS SITE 1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS. NAME (LAST, FIRST)PHONE N WITH AREA CODE DAYS'. NAME (LAST, FIRST) PHONE 4 WITH AREA CODE a zoq 3 U Beyii Mike- 20 -S� NIGHTS'. NAME (LAST, FIRST) PHONE q WITH AREA CODE NIGHTS: NAME (L T. FIRST) PHONE q WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME JURISDICTION IF CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION 1J v I MAILING or STREET ADDRESS �✓eo ndicalo 71 PARTNERSHIP ElSTATE -AGENCY CITY NAME INCORPORATION ❑ LOCALAGENCY❑ FEDERAL -AGENCY I o ZIPCODE PHONE p, WITH AREACODE ❑ INDIVIDUAL ❑ COUNTYAGENCY CITU NAME STATE ZIP CODE PHONE q, WITH AREA CODE PERMIT APPROVAL DATE s� OVGX/ v1 ' ER IT EXPIRATIGN DATE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME PGS JURISDICTION IF AGENCY # CARE OF ADDRESS INFORMATION ��✓ 8yy to indicate 11 PARTNERSHIP 11STATE-AGENCY 5-CORPORATION 1-1LOCAL-AGENCY 11FEDERAL-AGENCY lill-— MAILING or STREET ADDRE S ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME APPROVED BY NAME, PHONE # WITH AREA CODE STATE ZIPCODE PHONE p, WITH AREACODE � s 8 PERMIT NUMBER 0 �. IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. 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 # JURISDICTION IF AGENCY # FACILITY ID If If of TANKS at SITE EEI du 51 boo I I CURRENT LOCAL AGENCY FACILITY ID q PAc, APPROVED BY NAME, PHONE # WITH AREA CODE � s 8 PERMIT NUMBER PERMIT APPROVAL DATE s� OVGX/ ER IT EXPIRATIGN DATE LOCATION CODE CENSUS TRACT # SUPERV O DISTRICT CODE BUSINESS PLAN FILED DATE FILED ('i YES ❑ NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT IT B 7Q '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 \\\, F RMA (3-2-68) DATA PROCESSING COPY 0