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STATE OF CALIFORNIV WATER RESOURCES CONTRAOARD W: FORM `A': 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 U?r5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME 1 CARE OF ADDRESS INFORMATION 01 // 6-1-lks ADDRESS G C` NEAREST CROSS STREET ✓&abnixxw ❑ PAAfNERSHP ❑ UAR AGENCY 2 ( �- V '`� P I �J', 1v 'el ❑ 1o,DUAL O fAlIN1Y GENU' ❑ fE0E0.4L AGENCY CITY NAME K`T STATEZIP 7 ZIP CODE F]YIIYG SITE PHONE#,WITH AREA CODE S C \ b CA - TYPEOFBUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N It of TANK'N 77 RESERVATION or ❑ C Aq 6 t)6 Ls-2 3 3 '7 AT THIS SITE L ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FlRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE CY �l S 1 :o 209 S7 - M6 NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION $ CTII\: 5 MAILING or STREET ADDRESS ^ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY C 'I( I ell ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY b J • 6"1'A-y �^ ell DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE e-R I / r2 D S 112-00j-77 - so 3 III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME 11 11 CARE OF ADDRESS INFORMATION Uf L MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP Cl STATE-AGENCY 4 C ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY �JLS4 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODEPHONE N,WITH AREA CODE Z_t} 8 -5-7-7 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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 N AGENCY R FACILITY ID k `1.5cc , N of TANKS at SITE " CURRENT LOCAL AGENCY FACILITY ID N LAPPIEDIY.NA PHONE N WITH AREA CODE Cr l! � a\ PERMIT NUMBER PERMIT APPROVAL DATEIT EXPIRATION DATE `V LOCATION CODE CENSUS TRACT N ad ICT NESS PLAN FILED DATE FILED3 . )- ? z eYES NO /(CHECK• PERMITAMOUNT -J SURCNAROE AY00.NTJ RECEIPT N 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. FORM A(3-2-8B) •