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STATE OF CALIFORNIf WATER RESOURCESCONTROCBOARD J •: FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 14 COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) Cn 07 FACILITY/SITE NAME V CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bodo Micale ❑ PAIRNERSHP El STATE AGENCY 13�� w 2v INDIVIDUAL El MUNNAGEHCWIGN ElFEUEAALAGENCY ❑ CITY NAMESTATE ZIP CODE SITE PHONE k,WITH AREA CODE PN L4 CA 2 TYPE OF BUSINESS: [:] 2 D TRIBUTOR F—] 4 PROCESSOR ✓Bax d INDIAN EPA ID p RESERVATION or ❑ X of TANK's ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST.FIRST) PHONE Al WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAM ��•,�,(� CARE OF ADDRESS INFORMATION �YV Vl C MAILING or STREET ADDRESS ^�}} / ✓Dox to,rdcale El PARTNERSHIP ❑ STATE-AGENCY E• H /2 6 ❑ INDIVIDUAL 11 COUNT AGENCY ION ElFEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE G�A�P� c 23 s III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION C GS MAILING or STREET ADDRESS ✓Dox to indicate ❑ PARTNERSHIP Cl STATE AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CXECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. III. El Fi� 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 �# III AGENCY# FACILITY ID# L�{(- #of TANKS at SITE ® L_.�L_J ,2— I O CURRE T�CAL AGENCY FACILITY ID# APPROVED BY NAME PHONE a WITH AREA CODE I t PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ZS2 YES ❑ NO 6 CME K PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a BY: THIS FORM MUST BE ACCOMPANIED BY AT LEA;§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