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STATE OF CALIFORNIA WATER RESOURCES CONTROL OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 10 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/S}E N�ME• CARE?AD0ESSFORMATION C/T ,/ 1 t Tire ls'90-L ry ADDRESS NEAREESTT 1CROSS STTRRI ✓Soxbmeme ❑ PARTNERSHIP ❑ STATE AGENCY O 5_T1,Au L 4_— Cl EI NOWDUAL El COUNTY G C ORATION El _�LAGENCr 0 FEDERAL AGENCY 0 CITY NSTATE ZIP CODE SITE PHONE#.WITH AREA CODE AME o c,CTo A) cA R5-PO TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a If of TANK'# ❑ 1 GASSTATIDN ❑ 3 FARM w 5OTHER RESERVATION or El THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) TRUST LANDSEMERGENCY CONTACT PERSON(SECONDARY) I DAYS'Z(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE 1LAST FIRST) Y!')! Y W3-/6'a-3 I chi [1 /A�f Lsrl -/ - I NIGHT$: NAME( PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE /h&,%A1 S K tem f�C q73-7i L 11. PROPERTY OWNER INFOR14ATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADO7 F RMATION 44-k - i c S/ MAIl1JJW or STRE T ADDRESS ✓8ox to dicale ❑ PARTNERSHIP ❑ STATE AGENCY 'E..�&1 /�1 q`CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY ( GCC 1 ( LJ INDIVIDUAL ❑ COUNTY-AGENCY CI:�A� A STAIE� ZIPG�2-o� PHONE# ITHA%� � 111. TANK OWNER INF RMATION &ADDRESS - (MUST BE COMPLETED) 9L/-? os NAME CARE OF.A(LDREA INFORMATION r_ MAILING^ror STREET ADDRESS31 �Bo To Indicate EIPARTNERSHIP ❑ STATE-AGENCY ! O I�J RLpI'ICNORPORATION [ILOCAL-AGENCYFEDERAL-AGENCY DIVIDUAL ❑ COUNTYAGENCY CITY NAME � STATE ZIP CODE•�'l PHONE#,WITH AREA COD) IV. LEGAL NOTIFICATION AND BILLING ADDRESS liLl 3 CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APP )CAN T'S NAME(PRINTED&SIGNATURE) DATE 1 0 a LOCAL AGENCY USE ONLY COUNTYR JURISDICTION# AGENCY R FACILITY ID# If of TANKS at SITE m CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 'S LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 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. FORM A(3-2-88) \ DATA PROCESSING COPY �"f