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STATE OF CALIFORNIO WATER RESOURCES CONTRIPBOARD yEP...0 FORM 'A'-. UNDERGROUND STORAGE TANK PROGRAM fto ISITE 0V FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT E:]3 RENEWAL PERMIT 2`5CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ®4 AMENDED PERMIT [:]6 TEMPORARY SITE CLOSURE 51 I. FACILITY/SITE INFORMATION &ADDRESS- ( BE COMPLETED) FACILITY/S7 NAME CARE OF ADDRESS INFORMATION 00/1 &?/C- W61-41011, scry I'C,(-- -/8w to indicO 0 PAWNERWIP 0 STATE-AG90 ADDRESS NEAREST CROSS STREET 0 COWMTIM 11 LOCAL-AUNCY 0 MXM.AGENCY 0 INDMDJAL 0 MINWAGENCY CITY NAME CV_t_r�,, v STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA 1�(�S I 9SO TYPE OF BUSINESS: E]2 DISTRIBUTOR M ✓ x if INDIAN EPA ID # RESERVATION or I of TANKs E] 1 GAS STATION [:]3 FARM TRUST LANDS 1:1 aAT 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 NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION C0_l;fDrnirt, W Y C-0. MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 17 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0?n N . First Jwre* 1:1 INDIVIDUAL Cl COUNTY-AGENCY CITY NAMEZIP CODE WITH AREA CODE JfLn ,fo Q Ill. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) NAME 1CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP El STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 11 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. [:] u. 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# JURISDICTION# AGENCY# FACILITY ID# III of TANKS at SITE L21-o �Ll LL CURRENT LOCAL AGENCY FACILITY ID# ROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CEN SUSTRACTO SUPERVISOR--}D18 ICT CODE BUSINESS PLAN FILED DATE FILED YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCO ANTED BY ATL (1)OR MORE TANK PERMIT FORM'B'Appucnm(s),UNLESS THIS IS A CHANGE OF SITE INFORMATION FORM A(3-2-88)