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s STATE OF CALIFORA WATER 'RESOUR ESCO NTR' , B C RR OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM u m �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE °gQFC,L WP f M014 RK ONLY F -1I NEW PERMIT F—]3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I. NE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE z � Im 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION CARE OF. ADDRESS INFORMATION l✓d CURRENT LOCAL AGENCY FACILITY ID # MAILING or STREET ADDRESS FF /1/ o tiE% IUAB Lt}N QC0 ADDRESS ❑ FEDERAL -AGENCY CITY NAME REST CROSS STREET ✓ o indicate ❑ PARTNERSHIP ElSTATE-AGENCY y #, WITH AREA CODE I&qAf 64 CORPORATION ❑ LOCAL -AGENCY ElFEDERAL-AGENCY / Y -a-5?-1 ip L FEE CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME Y: STATE ZIP CODE S E PHONE #, WITH AREA CODE T0l CA `Jo2� &'SS S TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID # GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ATION or ❑ # of TANK'a AT THIS SITE (, EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE It WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE Crk I Nc C ZG�i-r ills 38 - 53-2.3 N6 NIGHTS: NAME (LAST, FIRSTT PHONE # WITH AREA CODE NIGHT,$: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BECOMPLETED) NA&jCV CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION OQ S(� C • l✓d CURRENT LOCAL AGENCY FACILITY ID # MAILING or STREET ADDRESS Bi�cc to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY IUAB Lt}N QC0 ��✓ Uli?TORPORATION ❑ LOCAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY ❑ FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE I&qAf 64 L94 3 '41S -a-5?-1 ip III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NA E JURISDICTION # CARE OF ADDRESS INFORMATION Agvg- �' y CURRENT LOCAL AGENCY FACILITY ID # MAILING or STREET ADDRESS ox to indicate El PARTNERSHIP ❑ STATE -AGENCY PERMIT NUMBER ��✓p LWrCORPORATION ElLOCAL-AGENCY❑ FEDERAL -AGENCY Q( ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITYNAME CENSUS TRACT k STATE ZIP CODEiqq PH�� WITH AREA CODE CHECK # � SURCHARG MOUNT G— 3 FEE CODE N .4 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. O if. ❑ III. Q/ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT 121$0 APPLICANT'S NAME (PRINTED & SIGNATURE) DATE !( LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # �) ' :5:�� # of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID # APP O ED BY NNA PHONE k WITH AREA CODE O PERMIT NUMBER PERMIT APPROVAL DATE PERMI , EXPIRATION DATE LOCATION CODE / CENSUS TRACT k SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES No DAT ILE 8 CHECK # PERMIT AMOUNT SURCHARG MOUNT FEE CODE RECEIPT # Y: THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANE OF SITE INFORMATION ONLY. FORM A (3-2-88) DATA PROCESSING "Copy