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STATE OF CALIFORNIA WATER RESOURCES CONTROL OARD "c E FORM A: UNDERGROUND STORAGE TANK PROGRAM _ o SITE _ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT E 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE F'a ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5 W 0 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 IV FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Srn mo k-0 ( „ rY10 �J j k e ADDRESS NEAREST CROSS STREET ✓IkNIbrd.I1 0 PARTNERSHIP 0 STATE AGENCY mC0_�' O IEDulCNO nENC ❑ FEDERAL- AGENCY LOONn CITY NAME �� STATE ZIP CODE �� SITE PHONE#,WITH AREA CODE CA q5� TYPE OF BUSINESS: � 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID # RESERVATION or �� AT THIS BITE I GAS STATION 3 FARM OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST`FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE Ci 1 mO' b1 LR NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME Imo, CARE OF ADDRESS INFORMATION G � MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCALAGENCY0 FEDERAL AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAML CARE OF ADDRESS INFORMAT,IgN� M0 1 1 a : ( Y lO �_bI I` C MAILING or STREET ADDRESS /� I/Box to intlicate 0 PARTNERSHIP 0 STATE- AGENCY ' O y� I ,j_„ O , 1:1 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 1 1 \O �Q DIVIDUAL 0 COUNTY-AGENCY CITY NAME STATES ZIP CODEPHONE#.WIT AREA CODE '\ o C9-- �9..- �Sa.ba 6 '31 1 a.�S r IV. LEGAL NOTIFICATION AND BILLING ADDRESS 9 L( ( C)Z) CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID It At of TANKS at SITE ffEl = = lCC CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT �k \ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LE b UV l_ I YES NO E] C f Z�c CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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. _ ORM A(3-2-88) � 1 DATA PROCESSING COPY