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STATE OF CALIFORNIA' WATER RESOURCES CONTR�r`00ARD " FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z .I, .. SITE ,� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONPERMANENTLY CLOSED SITE FJ ❑ 6 ONE ITEM El2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE W I.FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) W FACILITY/SITE NAME x CARE OF ADDRESS INFORMATION PAN C ADDRESS /� NEAREST CROSS STREET bMctle PARINEASNIP ❑ STATE RVERAGENCY -AGENCY J WRPoRAiION ❑ LOG#GENO ❑ RDEER I-AGR ❑ INDMDJAL ❑ ODIINI AGENGV CITY NAME A STATE SITE PHONE N,WITH AREA CODE ( CA S TYPE OF BUSINESS: ❑ MBUTOfl ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N If of TANWs RESERVATION or AT THIS SITE 5 OTHER ❑ 1 GAS STATION 3 FARM ❑ TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) ^ e ( PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) FV.�S,Q/-W� PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STR ET ADDRESS to indATIC ❑ PARTNERSHIP ❑ STATE-AGENCY E /L 17/ r A E O VIDUATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY Y�M1+IT ruV INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE d 66- f III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME r! —1 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ 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 WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. r 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 N JURISDICTION If AGENCY a FACILITY ID N a of TANKS at SITE FTT = = 10 o -417/ / E0 IQ 10 10- CURRENT LOCAL AGENCY FACILITY 10 N1/ APPROVED BY NAME PHONE M WITH AREA CODE ��' 1 Ka PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [C!HECKON ATICODE CEN8U5 T1IACTN 8UPERVISOR•DISTRICT CODE BUSINESS PP S N FILED NG DATE FILED2 z PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY:,'/led 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 ONL FORMA(3-2-88) w4w DATA PROCESSING COPY '�