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STATE OF CALIFORNIA WATER RESOURCES CONTRO•OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM o SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT jf,5t`HANGE OF INFORMATION 7 `L:IIIANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N O FACILITY7 ;NAME CARE OF ADDRESS INFORMATION 14 oblN l✓t11(;I ADDRESS NEAREST CROSSSTREET Rmlo indiGle 0 PARTNERSHIP 0 STATE AGENCY CORPORATION ❑ LOCALAGENCY CW FEDERALAGENCV (/✓, 26" ��•6 t �. Q CbY R) uKN ❑ INDIVIDUAL ❑ COUNTYAGENCY CIT".."IE STATE ZIP CODE SITE PHONE N,WITH AREA CODE LINCAKIJ CA 9Sz3/0 /6- 7$-Y01 TYPE OF BUSINESS @ DISTRIBUTOR 4 PROCESSOR I/Bax if INDIAN EPA ID p a of TANK's ❑ ❑ RESERVATION o 1:1AT THIS SITE [711 GAS STATION F-13 FARM FK 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE UKN NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE UKN LAKN II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMA ION MAILI 41SjET ADDRESS ✓Box intlicale 0 PARTNERSHIP ❑ STATE-AGENCY �� 0 CORPORATION 0 LOCALAGENCYFEDERAL-AGENCY /'e r r 0 INDIVIDUAL D COUNTYAGENCY CITY N ME STATE ZIP CODE PHONE p,WITH AREA CO ac C S$zr17/6-7297-55;3 III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION QS MAILING OI STREET ADDRESS -/Box io intlicale 0 PARTNERSHIP 0 STATE AGENCY 0 CORPORATION D LOCAL AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ECOUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS HECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. III.❑ C ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AIJD CORRECT. APPLICANT'S NAME(PRINTED A,SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCYAT FACILITY ID N M of TANKS at SITE 39 [01011IF101rol 101610101 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE UNvd PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE .7 '2, FO / YES El NO CHECKN PERMIT AMOUNT SUR CHARGE 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. FORM A(3-2-88) • DATA PROCESSING COPY • I