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STATE OF CALIFORNIA WATER RESOURCES CONTAtL'SUARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM = " �o 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 []7aaaUqLYCLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE Q / 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W FACIL /SIT NAME FCARE OF ADDRESS INFOR TION 5tj " O ADDRESS NEAREST CROSS STREET ✓Soa.16.11, D PAUNEBSHIP D STATE-AGENC" E .SI Y`li Pi`� ❑ cORrGRAnoN Cl IOCALMENLY D FEDEMLASEND ❑ INDIVIDUAL ❑ ODUNrr-AOENC( CITY NAME / A �� STATE ZIP CODE SITE PHONE N,WITH AREA CODE _J o PRQCE a Ll 9 CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 SSOR ✓Bax if INDIAN EPA ID n- F of TANKY ,Lt—�,'S/ RESERVATION or AT TNIS SITE ❑ 1 GASSTATION 0 3 FARM OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: AME(LAST FIRST) P ONE If WITH AREA CODE DAYS: NAME(IAST,FIRST) PHON NWITHAREA CODE lamas ao4 '18'- 181 ao9 94°8-OGa NIGHTS: NAME(LAST,FIRST) ONE a WITH AREA CODE NIGHTS: NAME(LAST, IFIST) PHONE K WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME ^ � F,} O Q`�-b_� CARE O,ADDRESS INFORMATION� ^ �I 1 i{7I- lU1 Gr- L 9 MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY `n D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ao ifV�t D INDIVIDUAL D COUNTY-AGENCY CITY NAME �[ - - STATE ZIP CODE PHONE M.WITH AREA CODE C aa III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME T) CARE OF ADDRESS INFORMATION e. MAILING or STRI ETDDRESS I ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION 1:1 LOCAL-AGENCY ❑ FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE..WITH AREA CODE to Ceti C/� IV. LEGAL NOTIFICATIONIM BILLING ADDRESS CHECK ONE(1)BOX INDICATING IRADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1.15� Ill. THIS FORM HAS BEEN COMPL D 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# JURISDICTION N AGENCY# FACILITY ID R M of TANKS at SITE lzil I do I I I I gq In 10 lo I I CURRENP.RCAL AGENCY FACILITY ID k APPROVED YN E NO NE N WITH AREA CODE OY` PERMIT N MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE q ail LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS P N flLE DATE FILED C - YES NO CHECK N PERMIT AMOUNT SURCHARGE AMOI FEE CODE RECEIPT If BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION O4 NL (3-2-881 \� DATA PROCESSING COPY t 7:�