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STATE OF CALIFORNIA WATER RESOURCES CONTRA OARD A• a FORM `A': UNDERGROUND STORAGE TANK PROGRAM " �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P Y CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME UA/ 635,$ aCAPE OF ADDRESS INFORMATION i✓ l ADDRESS // A n J� NEAREST CflOSS ST ✓ ei3rtle ❑ PAA7NERS4IP ❑ STATE AGENCY CG'POPAMMI ❑ PLAAGENCY 13FEDERALAGENCY .Ci \ ❑ IEIOMDAL ❑ COUNTY CITY NAME STATE ZIP CODE SITE PHONE N WITH JJJAREA COD7E CA - 95 A -e TYPE OF BUSINESS: ❑2 DISTRIBUfOfl Z4 PROCESSOR ✓Box if INDIAN EPA 10 N It of TANK'# ❑ 1 GASSfATION ❑3 FARM ❑ TRUST LANDS 5 OTHER RESERVATION or F-1 AT THIB SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: N911E RJST.FIRST , PHONE N WITH AREA CODE DAVE: +AME LAST.FI STf - PHONE N WITH AREA COD �/(^///y{' 1.t /�' 836—d� NIGHTS: NAME(Lr. FIRS PHONE Al WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION -AGENCY MAILING or STREET AION ❑ LOCAL-AGENCY FEDERAL-AGENCY Y#te 11 PARTNERSHIP ❑ STATE —7 / O v T �' O % D COUNTY-AGENCY CITY NAME / STA66i,_ 1 E'Q,� ZIP CODE PHONE C WITH AREA CODE �i1L `-�,_ Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME _ CARE OF ADDRESS INFORMATION a . s MAILING or STREET AD i I. to intlATlt0 ❑ PARTNERSHIP ❑ STATE-AGENCY STS 11 INDIVIDUAL ION ❑ COUNT AGENCY 13 LOCAL-AGENCY 11 FEDERAL-AGENCY CITY NAME STATS/' I ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICAT ON AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 k JURISDICTION N AGENCY R FACILITY ID# k OI TANKS tl SITE UP-] 10003 CURRENT LOCAL AGENCY FACTO ID,M APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER VN N PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUB�ACT II BUPERVISO ISTRICT CODE BUSINESS PUN FILED ❑ DATE FILED 7-7 2/ 2 Deo 3 YES NO U/ CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BT'; THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `Br APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-BG)