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STATE OF CALIFORNIP WA TER RESOURCES CONTRAOARD FORM 'A': t? UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT PW CHANGE OF INFORMATION 7 PERM=CLOIIDONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSUREI. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION uoa A Ce..-. , WLSADDRESS LNEAREST1 STREET ✓guzro ibole � pNlRkp9tp � 31AlEAGFNLY � II�W'Lf" 0 aAGDCYCITY NAME ZIP CODE SITEPHONE k,WITH AREA CODE 0_1< 0 Po9 S3 aa � � TYPE OF BUSINESS: ❑2 CA ❑4 PROCESSOR ✓BozdINDIAN EPA ID k ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS or ❑ `� AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(IAST,FIRST) PHONE k WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CAPE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 13COUNTY-AGENCYCITU NAME STATE ZIP CODE PHONE k,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. ❑ IL ❑ 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 k FACILITY ID M k of TANKS at SITE I Uv I l I q I9 u U CURRENT LOCAL AGIMERMiT Y ID k APPROVED BY NAME PHONE k WITH AREA CODE c_.IsPERMIT NUMBERPERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIOON CODE AC(T�# SUPERVISOR-DDIISTRICT CODE BUSINESS PLAN FILED DA Fl /T/'G� y2— I YES E] NO � 5 `ICHECK# UNT SURCHARGEAMOUNT FEECODE RECEIPT# By; 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. ` RM A(3-2-98)