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,�.ajpp;r r ,"M1�I STATE OF CALIFORN WATER RESOURCES CONTR BOARD We' A FORM `A': UNDERGROUND STORAGE TANK PROGRAM m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC AGILITY/SITEI AM ARK ONLY ff, NEW PERMIT RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT M ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRFSS INFORMATION ADDRESS NEAREST CROSS STREET �toindicale El PARTNERSHIP ElSTAH-AGENCY /� CORPORATION 11LOGAL-AGENCY ElFEDERALAGENCY C/ ❑ 'NDIVIDUAL ❑ COUNTY- AGENCY CITY NAME STATE ZIP CODE SITE PHONE M,WITH AREA CODE ,o 95Zr� CA ` �2v�` 2 TYPE OF SINESS ❑ 2 DISTRIBUTOR ❑ a PROCESSOR -/Box it INDIAN EPA ID # #of TANK's 9 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS VATION�r ❑ (� o AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS- NAME{LAST,FIRST) PHONE#WITH AREA CODE q NIGHTS: NAME(LAST,FI T( HONE#WITH AREA CODE NIGHTS. NAM E(LAS ,FIRST) PHONE#WITH AREA CODE ew 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <Q'r. CORPORATION C2LOCAL-AGENCYC3 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE I11. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS _�f� VX.x fo indicate ❑ PAHTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOIL INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. If. Rf III. THIS FORM HAS BEEN COMPLETED CINDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLE T'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE &NL Q,e COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE EH I I I I L I I 1 1,u Lo D I �,, 1 ) 1 -4 F7o 1__:?� CURRENT LOCAL AGENCY FACILITY ID# APP VED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATIE FILE 3.00 YES ❑ NO Q '/ J uJ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Y: IIIIIIIIJ 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. FORMA(3-2-88J DATA PROCESSING COPY ��