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STATE OF CALIFORA WATER RESOURCES CONTR L BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM o Z SITE (o FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o ( l; / COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 NEI LOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE A I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A W FACILITY/SITE NAME / _ i CARE OF ADDRESS INFORMATION ADDRESSLOCAL AGENCY // " ' � ARE ST CROSS STREET ✓Box to Wictle ❑ PAUNEASRIP ❑ STATE- AGENCY / V Y �. tit)a&4_,/j�) � ,(�� Cl INDIVIDUAL ❑ COI AGENCY EARL- ENCY CITY NM STATE ZIP C DE SITE PH NE#,WITH AREA CODE 7�b C"K C�4j CA S Zb 2,0 1 TYPE OF 8 ESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a ',L�///�, Al of TANK's I GASSTATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or ❑ v /A AT THIS SITE 6 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) , PHONE N WITH AREA CODE DAYS: AME(LAST,FIRST) PHON WITH AREA CODE %w. 9 (- Llbl A NIGHTS: NAME(LAST,FIRST) PHONE#WITH A EA CODE NIGHTS'. NAME LASL FIRST) PHONE P WITH AREA CODE S A P/A IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAIF CARE F ADDRESS INFORMATION V I ✓v V✓W� MAILING or STREET ADDRESS ^ I Nix Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL- GENCY ❑ INDIVIDUAL Cl COUNTYAGENCY CITY NA STATE ZIP CODE PHONE ITH AREA CODE Tbc � C,4 ��?�r, - 6 a III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION A w-�. MAILING mSTREET ADDRESS -,x`Be.to'ad,cate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#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. it. ❑ 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 COmNTY R JURISDICTION# AGENCY R FACILITY ID# #of TANKS at SITE L 6 s vIdolo Is CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NA PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE P RMIT %PIRATION DATE LCHECK'# DE CENSRACT M SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DATE FI D �Itj YES NO S/ js 1 c" PERMIT AMOUNT SURCHARGE OUNT FEE CODE RECEIPT# BY: 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. FORMA(3-2-88) DATA PROCESSING COPY �