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STATE OF CALIFOR4 FORM `A': WATER RESOURCES CONTE BOARD SITE UNDERGROUND STORAGE TANK PROGRAM / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / "m COMPLETE THIS FORM FOR EACH FACILITY/SITE o MARK ONLY ❑ I NEW PERMIT I C9.IFOp NSP ONE ITEM ❑3 RENEWAL PERMIT �5 CHANGE OF INFORMATION 2 INTERIM PERMIT 0 q AMENDED PERMIT ❑ T PE I. FACILITY/SITE INFORMATION &ADDRESS — 06 TEMPORARY SITE CLOSURE #tY=CLOIEDSITE )-A W LITYisIT AME (MUST BE COMPLETED) L7 �`�, CARE ADDRESS INFORMATION 0 ADD E55 �Y 411. NEAREg7 CROSSSTREET CITY NAME /v/ ✓BMIDindom,, ❑ PARTNERSHIP ❑ STATE gGENGY 0 CORPORATION ❑ LGcu_ TATEAI- c LORI STATE 0 INDMDUAL 0 GOUNIYAGENC ZIP CODE SITEPH NE#,WITHAREACODE TYPE OF BUSINESS: LJ "PROCESSOR ✓BOx if INDIAN EPA ID #A 2DISTRIBUTOR �.L f/ � I 1 GAS STATION 3 FARM El 5 OTHER RESERVATION Or ❑ 1 Y EMERGENCY CONTACT PERSON(PRIMARY) TRUST LANO / /1 N of SS DAYS: NAME(LAST,FIRST) EMECY CONTACT RG N AT THHISIS SITE PERSON(SECONDARY) PHONE It WITH AREA CODE DAYS: ME(LAST,FIRST) NIGHTS: NAME(LA I T) b t q() PHONE#WITH AREA CODE PHONE#WITH AREA C DE NIGHTS' ME(LAST,FIRST) A II. PROPERTY OWNER INFORMATION &ADDRSS2-� J PoexwlrHgREAcoDE MUST BE COMPLETED) �y a CA ED AODRESS INFORMATION MAILING or REST ADDRESS (�A N Box to ,dicm, CORPORATION 0 PARTNERSHIP CITY NAME 0 LOCAL-AGENCY STATEAGENCY 1.�w /�T❑�•INDIVIDUAL CICOUNTY-AGENCYF OEgAL- GENCY ST • ZIP CODE PHON ITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — 1V6r� f E / (MUST BE COMPLETED) 6Rte/[, �� /. __ - . �j CA�IRE/OFAAQDDRESS INFOHMATION MAILIN STREET ADDRESS /f (,(/{R•A O. COX 151 0 CORPORATION Box to indicate PARTNERSHIP 0 STATE- CITY NAME 0 INDIVIDUAL 0 LOCAL-AGENCY FEDE AGENCY 0 COUNTY-AGENCY AGENCY d� r STATE ZIP CODE u ,w — / PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS -F CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED -GTN LEGAL NOTIFICATION AND BILLING I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY M JURISDICTION N AGENCY# FACILITY ID N N of TANKS at SITE UYUJ CURRENT LOCAL AGENCY FACILITY ION1-1� O 3 APPROVED PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N 'z �v. � SUPERVIS R•DISTRICT CODE BUSINESS PLAN FILED D TE FILED CHECKN PERMIT AMOUNT YES ❑ NO / SURCNARGE AMOUNT FEE CODED RECEIPTN BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM V APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) 0 DATA PROCESSING COPY