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STATE OF CALIFORNIA * WATER RESOURCES CONTROL F&RD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C1t�lOPN1� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F11 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM Fl INTERIM PERMIT El AMENDED PERMIT 6 TEMPORARY SITE CLOSURE S-3 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) F CARE OF ADDRESS INFORMATION FACILITY/SITE NAME ze, YIS ✓( NEAREST CROSS STREET I071iGR TION ❑ _ g FTAE➢FAN A-GBO ADDRESS ❑ YIUYDIW ❑ GONn AGENCY L S P m C STATE ZIP CODE SITE PHONE M,WITH AREA CODE - CHY NAME CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA IDN I of TANK'B RESERVATION orAT THIS 817E F] 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE . PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME C� ��0.✓E Ci.y,��" HARING or STREET ADDRESS ✓Box to ATIIO ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY 3 N ip ❑ INDIVIDUAL ❑ COUNTY AGENCY !� STATE ZIP CODE PHONE N.WITH AREA CODE CIN NAME 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME C lPv-P Lc. nod MAILING m STREET ADDRESS VB..to RATIe ❑ PARTNERSHIP ❑ STATE FEDERAL EDERA ENCY AGEN ❑ NDIVIDUALION O COUNTY AGENCY ❑ FEOERALAGENGY STATE ZIP CODE PHONE*WITH AREA CODE Cl TY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRSSE SHOULD BE USED FOR SOTM LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ III•❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY JURISDICTION � AGE FACILITY ID 0 Al of TANKS BI SITE o b a = © c c; L CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE S WITH AREA CODE _ L!� 8-S � PERMIT EXPIRATION DATE PERMIT NUMBER PERMIT APPROVAL DATE LOCATION CODE CENSUS TRACT N BDPERYIBDR'DISTRICT COO[ BUSINESS PLAN FILED DATE FILED YES NO 3 S 7 BY: FEE CODE RECEIPT 11 �C/yO CMECKN PERMIT AMOUNT SURCRARGE AMOUNT �. O THIS FURY MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($),UNLESS THIS IS A CHANGE OF SITE NffORMATION ONLY U IuHMAwz00)