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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': W '. UNDERGROUND STORAGE TANK PROGRAM ,gym SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Cl COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONE ITEM El I NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 1-17 PERMANENTLY CLOSED SITE fV 2 INTERIM PERMIT E] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION /ar/Ps ADDRESS C NEAREST CROSS STREET ✓Bow 1,lndicele ❑ PASTNEFSHIP ❑ STATE AGENCY 103 NONIDOASE�ION 1-1 LOCAL AGENCY 0 13 COUMYAGENCy FEDERAL AGENCY CITY NAME STATE ZIP CODE " SITE PHONE p.WITH AREA CODE TYPE OF BUSINESS: 2 DISTRI OR 4 PROCESSOR ✓Dox if INDIAN EPA IDA 1 GASSTATION FARM 5 OTHER RESERVATION or ❑ #of TANK's TRUSTLANDS - AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME HAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAMELA TFIRST)IRST NAME(LA PHONE ft WITH AREA CODE S rnCu/nG 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 542,1 C ! S —T MAILING or STREET ADDRESS I/130x to intlicalo LlPARTNERSHIP ❑ STATEAGENCYElCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY CITU NAME GNDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicalo ❑ PARTNERSHIP Cl ❑ RPORATION ElLOCAL-AGENCYElFEDERALC-AGENCY CINAME Of INDIVIDUAL ElCOUNTY-AGENCYSTATE ZIP CODE PHONE p,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 3� JURISDICTION �� AGENCY# FACILITY ID ( � #o1 TANKS at SITE 3 CURRIE C ACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE T� I (S E 'I PERMIT NUMBER OVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED or a 3aaZ 3a YES ❑ NO ❑ ?-g'`70 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: !� �u J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM rB'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(N-2-88) - \c� - b DATA PROCESSING COPY