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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r o. r FORM 'A': , UNDERGROUND STORAGE TANK PROGRAM = " e SITE CI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE "'•�^-"—'" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA CLOSED SITE F"J ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G N I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) A W FACI TY/ IT,E.NAAMnE-_ ' a / CARE 9FADDRESS INFORMATION ADDRESS �/�� !• - /' -^ NEAREST CROSS STREET ✓Box le ilodale ❑ PARTNEASNIP ❑ STATE AGENCY NV /I l L 1/7 l/(VJ Ly) ❑ CMPDRATION ❑ LOCAL AGENCY ❑ FEDERAL Cl3-7 INDNIDUAL ❑ COUNTY AGENCY CITY NAME A STATE ZIp,C�E .� TE,H� WITH AREA CODE GDO 1 CA Y G7 Y/ V })(7G TYPE OF BUSINESS: ❑p TRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID 4 I GAS STATION 3 FAflM ❑ 5 OTHER RESERVATION or M of TA HIS SI ❑ TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) S: NAME(LAST,FIRST) P ONE.WITH AREA COD€ DAYS'. NA (LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST IRST) ONE a WITH AREA CODE NIGHT J($�ZyAx ME(LAST.FIRST) � -PPHONE a WITH AREA CODE 4 A ✓v(/+ II. PROPERTY OWNER INFORMATIOk &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILI o STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY El INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE 4,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. pr II. ❑ If. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID 4 B of TANKS at SITE Do 2 S d 10 CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NA E PHONE M WITH AREA CODE Ag- L -7 PERMIT NUMBER PERMIT APPROVAL DATE P RMIT EXPIRATION DATE [C±HECK* ODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED YES � NO �' / PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: THIS FORM MUST BE ACCOMPANIED BYATLEAST(1)OR MORETANKPERMIT FORM 'B'APPLICATION(S), UNLESSTHIS ISACHANGEOFSITE INFORMATION ONLY. / FORM A(3-2-88) 10 DATA PROCESSING COPY 0