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STATE OF CALIFORSA WATER RESOURCES CONIOL BOARD LE^l Of M FORM 'A': UNDERGROUND STORAGE TANK PROGRAMAo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° I c COMPLETE THIS FORM FOR EACH FACILITY/SITE `<r�faaH�P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION I.K 7 PERMANENTLY CLOSED SITE 1•� ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE h I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FAC- ILITV/SITE NAME CARE OF ADDRESS INFORMATION MIF 4091 A r ADDRESS /,.•� NEAREST CREET ✓Eal0lydwle ClPARTNERSHIP ❑ STATEAGENCY D ✓ • 2, Cl WRPOPArON atIBCAIAGENC/ ElFEOEMLAGENCY Rnif 0. E3 INDIVIDUAL ❑ COUND AGENCY CIT'^'^`•� STATE N `CODE SITE PH NE ,WITH AREA CODE i CA g5%�y4 tor{ ` 6R-Z r3 Trt OF BUSINta>: ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA 10 4 ❑ I GAS STATION 3 FARM 5 OTHER RESERVATION or / ' #of TANK's ❑ TRUST LANDS ❑ u o AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS:,NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE ti(i e(L7011 (17-M ,6 z UK tj NIGHTS, NAME(LAST,FIRST) - HONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE ((�y(,,, /✓/4arirz4 6 - UK" II. PROPERTY OWNER IN 0RM'ATIO &&ADDRESS— (MUST BE COMPLETED) NAME 54ME AS z CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCYLl INDIVIDUAL ElCOUNTY-AGENCYCITU NAME STATE ZIP CODE PHONE 4,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORM'Afr Q I r MAILING or STREET ADDRESS ✓Box t intlicate ❑ ARTNERSHIP ❑ STATEAGENCY•O. ox z4 ❑ INDIVILl DUAL [],PARTNERSHIP AGENCY ❑ FEDERAL-AGENCY ITV A E ST E ZIP CODLLLEJJJ CCCOOO HONE 4 WITH AREA CODE /c for 1952Z 3 104 36 -29/3 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It AGENCY# FACILITY ID If At of TANKS at SITE 3 q OD zo e- CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE#WITH AREA CODE W 4, PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECTLK# TION CODE CENSUS TRACT N� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F ED pp L31Q/ YES ❑ NO �� y O' c PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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. FORMA(3-2-68) • 0 DATA PROCESSING COPY