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STATE OF C;ALIFORNIP WATER RESOURCES CONTROROARD "`'' a u: : - 1 � e FORM A: UNDERGROUND STORAGE TANK PROGRAM Z SITE , FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE c9LFO0.--"�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE r W ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A FACILITY/SITE NAME CARE OF ADDRESS INFORMATION m el& f. C LL I be r+-scs n tAD ne .- ADDRESS NEAREST CROSS STREET f2ap ✓Bor to Nose ❑ PARTNERSHIP ❑ STATE AGENCY L-ITCj Or UJ_eV,So([I}y�D�IRRa 0 INONIOUII/�� (jcoN�n�cE�Nc ❑ FEDERALAGENCY CITY NAME �� i STATE —1 JE��O SIQx PHONE9 p�J10AREA .; 1q a TYPE OF BUSINESS. 2 DISTRIBUTOR 4 PROCESSOR I/Box if INDIAN EPA ID a _ It of TANK's RESE El1 GAS STATION ❑ 3 FARM [ JMMHER TRUSTVATION LANDS or ❑ "�— AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(I-AST.FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE j&me5i, F. CuA bens n 2.9 369,1 d'v �— NIGHTS'. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION �ame�, �• C,u � r, �- MARLIN or STREET ADDRESS Y`Box to indicate 11 PARTNERSHIP ❑ STATE-AGENCY GI'�.� 1-1 CORPORATION ElLOCAL-AGENCY ClFEDERAL-AGENCY LAIBTNDIVIDUAL ❑ COUNTY-AGENCY CITY NAMESTATE ZIP CODE PHONE p,WITH AREA CODE Lit- � I 9 5 a y 0 2 09 3(09 III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax W indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE a.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. ❑ II. 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&SIGNATURE] . DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# Al of TANKS BI SITE ffIR P-CILITY 10# APPROVED BY NAME PHONE N WITH AREA CODE c, 6E7 -PERMIT APPROVAL DATE PERMIT EXPIRATION DATE NSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDrl qt 1I YES � NOMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 ON FORMA(3-2-88) DATA PROCESSING COPY