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in STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': _ m UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - , C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 21�, NEVV PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 10 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET mineirale ❑ PARTNERSHIP ❑ STATE AGENCY Cil �i ),l '7 n CORPORATION ElLOCAL AGENCY 1:1FEDERAL AGENCY ✓ J G l!'1..E' it ✓� /cY' ❑ INDIVIDUAL ❑ COUNTY AGENCY 00 CITY NAME1 ), C. 6STATE ZIP COD ITE PHONE p.WITH AREA CODE D V 1 L E�i,LI 09 33 �F-I'3$b TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Rox i(INDIAN EPA ID # RESERVATION or y�/ yyF1 #a1 TANK'a ❑ 1 GAS STATION ❑ FARM ® SOTHER TRUSTLANDS ❑ /' /1 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 ER T a NIGHTS. NAME(LAST,FIRST) PHO E p W11H AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE ao a II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION a— T. L Inc , MAILING or STREET ADDR SS ✓$$wwi�to Indicate D PARTNERSHIP D STATE-AGENCY p ��``''�� ( CORPORATION D LOCALAGENCYD FEDERAL-AGENCY . 0 ., O D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE CFS ( 9o9) 33q- t38o III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION me us propei MAILING or STREET ADDRESS ✓ ox tD PARTNERSHIP D STATE-AGENCY 17 CORPORATION N D COAGENCY 11 FEDERAL-AGENCY [I INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.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 A,SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #BI TANKS at SITE m = = 10101113171 (ol1010101 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE / Ll PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRAC(T`/M!�1 SU ERVISOR-OISTR T CODE BUSINESS PLAN FILED DATE FILED (�ry © 3, b V YES [:] NO � — lYl 00 CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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. FORMA(3-2-88) 0 DATA PROCESSING COPY 0