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11fi1"".' l--yor.+a n'SaFm^r^ar,...:^^t- a.M1..en•m�mo. STATE OF CALIFORNIF WATER RESOURCES CONTROL OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITIE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION CZ7 PER LOSED SITE !� ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1 •d 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ca FACILITY/SITE NAME - --''^^ ^^eCARE OF ADDRESS INFORMATION ri C-k — ADDRESS uNEAREST CROSS STREET ✓6orbMM ❑ PAAINERSHIP ❑ STATE-AGENCY N /O C 0 CORPORATION 0 LOCAL-AGENCY 13 FEDERAL-AGENCY 1... 0 INOMOUAL 0 COUNTY AGENCY CITY NAMEA, STATE ZIP CODE SITE PHONE N,WITH AREA CODE T�XAJ�I: cA dao 3!0&'- 4/ 955 TYPE OF BUSINESS: ❑p DISTRIBUTOR 4 ROCESSOR ✓Box 6INDIAN EPA ID N ❑ 1 GAS STATION FARM �OTHER RESERVATION of #01 HISTANSITE O 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#WITH AREA CODE o Can9 3(0�- HISS NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) NAME S 1 . -tD— CARE OF ADDRESS INFORMATION MAILING or BEET ADDRESS G ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME r+ ; /-Q CARE OF ADDRESS INFORMATION MAILING or STRIfET ADDRESS --/1-L_--. ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 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. II. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY M FACILITY ID M R of TANKS at SITE ml = = 10, 0N DO / CURRENT CAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE i PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NO ❑ A FILED ,f n PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY v THIS FORM MUST BE ACCOMPANIED BY AT LEA jj OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON5"� FORM A(3-2-SO) DATA PROCESSING COPY VVV ✓