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5 x WCF' xyf STATE OF CALIFORNIA* WATER RESOURCES CONTROL ARD FORMA': UNDERGROUND STORAGE TANK PROGRAM m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION O<IIFORN�P COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 1pf CHANGE OF INFORMATION 7 PE MANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1-57-01 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAM CARE OF ADDRESS INFORMATION _b4//bZ(1 L/1KM�N' n A NEAREST CRO/SS STREET ✓Bm loiMirs,O ❑ LoCk.AGENPARTNERSHICl FEDERAL AGENCY ADDRESS / Fx,� l/'��'^ ///n V/N�I/� INONIGUAL N ❑ COUNTY AGENCY CY ❑ FEGEM4AGENGY CITY NAME S g / i'1 C C STATE ZIP CODE SITE PHONE'p.WITH AREA CA D 9 ✓ N TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ <PROCESSOR Box if INDIAN EPA IDR of TANK'IRESERVATION or AT THIS SITE ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS' NAME(LAST,FIRST n A' �� I I IO Wl— 21�A u n� (*,em PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST n ///PHONE Al WITH AREA CODE NIGHTS: NAME(LA ,FIRST) II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME See �5 MAILING of STREET ADDRESS ✓Ror�fo in0icale ❑ PARTNERSHIP [3 STATE-AGENCY ❑ILDRPORATION ❑ LOCAL AGENCY Cl FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE N,WITH AREA CODE CITY NAME 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION V d' �1.r✓ " vt Lfi- MAILING or STREET ADDRESS Z Ipp� '/B..RPORATIe El PARTNERSHIP El STATE-AGENCY 3 / L4S C Qiy T� INDIVIDUALON COUNTY AGENCYLOCAL-AGENCY El FEDERAL AGENCY �TATJF ZIP C � PHONE N,WITH AREA DE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVB ADO111i SHOULD BE USED FOR BOTH 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. DATE APPLICANT'S NAME(PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY II CODUNI�TY�# JURISDICTION• AGENCY R FACILITY IDR R of TANKS at SITE m a � 5 Doo C URRENTFACILITY ID N LAPPROE PHONE R WITH AREA CODE 6 M ADo r, w'��'PERMIT APPROVAL DAMIT EXPIRATION DATENSUS TRACT# SUPERVISOINESS P SN FILED NG DATE FILED ^�7/i`6 d L ❑ ❑ Y:RECEIPT# BY:RYIT AYOUNT BURCHARG 1 THIS FORM MUST BE ACCOIWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. V FORM A(3-2-88)