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STATE OF CALIFORNIO WATER RESOURCES CONTRONOARD FORM 'A': a SI UNDERGROUND STORAGE TANK PROGRAM : ~ \ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FOR EACH FACILITY/SITE Et RK ONLY N;W PERMIT 0 3 RENEWAL PERMIT NE ITEM `)-"IL—. 0 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ITE I7 INTERIM PERMIT E q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O� Oa I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ao FACILITY/SITE NAME �-' CARE OF ADDRESS INFORMATION 170/X Y-a D /YID% P,o /� ? 7 s Ttv uia. A ESS NEAREST cRoss STREET 1 Boy dl ri 11 PARTNERSHIP ❑ STATE AGENCY I� CITY NAME AN)AATION 0 LOCAL-AGENCY IDFEOEAAL-AGENCY -I AINOIVIDOAI LlCOUNIYJGENCV IA.?15Jt� STATE P CODE F e SINESSITE PHONE#,WITH AREA CODE 00 x" CA ✓��/VV n �3 � : � 2 pISTRIBl1TOR �4 pROCEBSOB Box iI INDIAN EPA ID p -/,7 GASSTATION 3 FARM 5 OTHER RESERVATION orRUSTUNDS N❑ NK's EMERGENCY CONTACT PERSON(PRIMARY) A7 THIS SITE 3 DAYSNAME(LST, EMERGENCY CONTACT PERSON(SECONDARY) : ATFIRST) PHONE H WITH AREA CODE DAYS: NAME(LAST,FIRST) 3c,-/ ' � ' .A � PHONE H WITH AREA CODE Hl6 r5w) 44m, TS: NAME(LAST,FIRST) HONE H WITH AREA CODE GHTS: NAME(LAST FIR ) 6. J 51"e A / PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) E / ///)7 e_ C FAESS INFGRMATIGN C/ L_. U o Y-Y JC✓7l/G�7 Z�'274/sG M ING ar STRAAAEET ADDRESS ✓Box to intlicate 0 PARTNERSHIP ❑ 'TATEAGENCY�. Ojy/ �' CORPORATION El LOCAL 0 FEDERAL-AGENCY TV NAME 0 INDIVIDUAL 0 COUNTY-AGENCY �( STATE ZI ODE PHONE a,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) 25 CA OF ADDRESS INFORMATION S �S4ME i9S _� .ICING or STREET ADDRESS Oma_ ✓Bax to indicate ❑ PARTN ❑ ERSHIP ❑ STATEAGENCYCORPD ❑ LOCAL-AGENCY 0 FEOEFW AGENCY NAME 13 INDIVIDUAL AL 0 COUNTY-AGENCY 5 TE IP CODE EdQNE#,WITH AREA CODE IV GAL NOTIFICATION AND BILLING ADDRESS ra CHECK ONE(1)BOX INDICATING WHICH ABOVE...DRESS SHOULD_ - ------�----•- uuw BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY y COUNTY p JURISDICTION p AGENCY p FACILITY ID p �b #of TANKS at SITE Uv 1 6 � 0 03 RRENT LOCAL AGE FACILITY IDk 37 �j� APPROVED BY Nq `v�- PHONE k WITH AREA CODE MIT NUMBER PE APPROVV DAT PERMIT EXPIRATION DATE L TION COD SUS TR1ACT p Y S RVI OR-DISTRICT DE BUSINESS PLAN FILED 0 oC 7 I-?- DATE FILED YES NO ECK M RMIT AMOUNT RCHARGE AMOUNT FEE CODE RECEIPTp BY: THIS FORM MUST BE ACCOMPANIED BYAT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. (FORM A(32-88) J DATA PROCESSING COPY