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STATE OF CALIFORNO WATER RESOURCES CONTFIO BOARD A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FA ITY/SITE `'"�oe_ " MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE TLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ell ADDRESS NEAREST CROSS STREET ✓ V 0 PAIITNERSIIIP ❑ STATE AGENCY [?!/CORPORATION 0 LOCALAGENLY 0 FEODUL AGENCY (%e/=S fi ❑ INomoua ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE Un CA TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4_PRBCfSSOR I ✓Box if INDIAN EPA ID p —11 RESERVATION or Mol TANK'rt E] 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE {/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE /lain NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME /t CARE OF ADDRESS INFORMATION �/ �� /l/ o MAILING or STFIEET ADDRESS to intlicale ❑ STATE-AGENCY �// /� , �� '"�� RPORATION LOCAL-AGEN 0 FEDERALAGENCY Vl //y EE INDIVIDUAL ENCY CITY NAME _ STATE ZIP CODE �i PHONE#,WITH AREA CODE Q/) l_- �✓ �� ' S J/��O III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MG S MAILING or STREET ADDRESS ✓Bae to I,dIcate 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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. ❑ if. 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY M FACILITY ID M M of TANKS at SITE nil I cl)I c1� � 1 01 o 1o E-1 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE lellpCIL) —2— PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA�N�CODE CENSUSTfR�ACTk SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO ❑ DATE FILED .�w ES CHECK F J PERMITOAMO'UNT SURCHARGE AMOUNT FEE CODE RECEIPT N IpBBY: ^ U; 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) )