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STATE OF CALIFORN* WATER RESOURCES CONTROBOARD A FORM `A': UNDERGROUND STORAGE TANK PROGRAM _ �) SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATI Z IQ - COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERM OSBO SIT N ONE ITEM ❑2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) FACT /SITE NAME fY" • _11L. - CARE OF)MORESS INFORMATION ADOR ' *NEST CR STR ✓Bmbi6Jb ❑ PWITNEBNP Cl SrAIE-AGDO ��LuN� ❑ IMVMTOI ❑ LOGL.IGHIt.Y /��"'111 ❑ IN MR ❑ coum Ama CI E STATE SITE PHONE N,WITH AREA CODE b DYE CA TYPE OF BUSINESS: ❑2 D15TRIBUTOR ❑ ,IR ✓Box N INDIAN EPA ID N RESERVATION or ❑ Cr4�dp�7 b 86.E •of TANK'e AT THIS SITE 6U ❑ 1 GAS STATION [:]3 FARM 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*WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS NAME(UST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) NAMEA CARE OF 0 ESSINFORMATION �cJ MAIU;VSTREErAPOREW vitax to iwimm, ❑ PARTNERSHIP 0 STATE-AGENCY ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY a OA INDWIOUAL ❑ COUNTY-AGENCY CIT'NA STATE 11 ZIP C`OD`E PHONE N,WITH AREA CODE 70 III. TA K OWNER I ORMATION & ADDRESS - (MUST BEECCOMPLETED) NAME+ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to inokete ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIP CODE 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: I. ❑ II. V III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) - DATE LOCAL AGENCY USE ONLY (✓ a\ 7 COUNTY Y JURISDICTION N AGENCY N FACILITY ID N GGN o1 TANKS at SITE (^ 16 CURRENT®AGENCY FACILITY = APPROVE Do NAME 3 / PHONEN0 AREA 0 ,a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT* SUPERVISOR-DIS CT CODE BUSINESS PLAN FILED ATE FILED / YES ❑ NO 4 O¢ CHEC * I PERMIT AMOUNT SURCHARG OUNT FEECOOE 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.C^ FORM A(5-2-88) "" F— • 1 raC. C�Y`{} DATA PROCESSING COPY J