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STATE OF CALIFORN% WATER RESOURCES CONTR&OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE FJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE I -4 , I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION C JA/e S ADDRESS '�A/� NEAREST CROSS STREET bidimte ❑ PARTNERSHIP ❑ STATE-AGRIG/ 6D � /wF/o IN ClIWNPoRFLION 130OUryCl LOCAL AGENCY D ❑ FEDERAL AGENCY CITY NAME STATE ZIP CODE SITE PHONE ft,WITH AREA CODE vockl6k-l" CA s2os- TYPE OF BUSINESS: ❑ 2 D TRIBUTOR ❑ 4 PROCESSOR '/Box it INDIAN EPA ID a RESERVATION or K of TANK'1 ❑ 1 GASSTATION LIZARIA ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NA" CARE OF ADDRESS INFORMATION 1hojMAILINGor STREET ADDRESS N/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 6 1J0 11 NDIIVIDUALION ❑ COUNT AGENCY 0 LOCAL AGENCY ❑ FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE &c k faN176,201i 1 Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION gamt Ines MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY 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. Vf 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION B AGENCYIN FACILITY ID N R of TANKS at SITE k/12 oa CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE k WITH AREA CODE Z-146 6m & PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHEC # DE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LEO 23 �� YES NO 6 �� PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. AI FORMA(3-2-B8) DATA PROCESSING COPY