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STATE OF CALII=ORNIS WATER RESOURCES CONTRO FORM `A': SITE C, UNDERGROUND STORAGE TANK PRO FACILITY/SITE, INFORMATION and/or PERMIT COMPLETE THIS FORM FOR EACH FACILITY/SITI MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 9<5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I L. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME t Q CARE OF ADDRESS INFORMATION CARE OF �A�7�TION CUR NT LOCAL AGENCY FACILITY ID # KX MAILING TR AD j,,(�y �`�fJ11❑ ESS ADDRESS ✓ Box to indicate CORPORATION INDIVIDUAL NEARESTROSS. STREET ✓Rnyloindicate ❑ PARTNERSHIP ❑ STATE -AGENCY 7 2_I r f �(i 54, ElCORPDAATION � LOCAL -AGENCY El FEDERAL -AGENCY ZIP CODE t/' �' �..1 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME f STATE ZIP CODE BY: SITE PHONE #, WITH AREA CODE ' .j -i i- e CA�'- TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box it INDIAN EPA ID II GAS STATION ❑ 3 FARM OTHER TRUSTT LANDS or ❑ ESERTIONEl AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS', NAME (LAST, FIRST}5 PHONE 4 WITH AREA CODE Ile DAYS. NAME (LAST, FIRST) PHONE # WITH AREA CODE r — e) NIGHTS NAME (LAST, f IHST) e PHONE In WITHAREACODE NIGHTS NAME (LAST, FIRST) PHONE H WITH AREA CODE ' f 5// II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME i Q C CARE OF �A�7�TION CUR NT LOCAL AGENCY FACILITY ID # KX MAILING TR AD j,,(�y �`�fJ11❑ ESS ✓ Box to indicate CORPORATION INDIVIDUAL ❑ PARTNERSHIP LOCAL -AGENCY U COUNTY -AGENCY ❑ STAT AGENCY 177FEDERAL-AGENCY CITY NAME/v,�,��Jy� , p STATE I ZIP CODE STATE ZIP CODE PHONE #, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION j FACILITY ID # # of TANKS at SITE [�) 17/ "i I 1 y I L❑ " I— J "i % CUR NT LOCAL AGENCY FACILITY ID # KX MAILINGSTREET ADDRESS ✓ Bax in indicate ElPARTNERSHIP ❑ STATE -AGENCY CORPORATION ❑ LOCAL -AGENCY D FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE I ZIP CODE I PHONE N, 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: h ❑ If. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT. APPLICANTS NAME {PRINTED B SIGNATURE} DATE LOCAL AGENCY USE ONLY COUNTY # Eul"�� JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE [�) 17/ "i I 1 y I L❑ " I— J "i % CUR NT LOCAL AGENCY FACILITY ID # KX APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CO E CENSUS TRACT # SUPERVIS R -DISTRICT CODE BUSINESS PLAN FILED YES Q INI DATE FILED — y CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1 } OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A 13-2-881 DATA PROCESSING COPY 1 S F -I a s