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STATE OF CALIFORNIP WATER RESOURCES CONTROMOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMo SITE 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 ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM (-11NTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q -4 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 F-� FACI /SI NAME CARE Of DDRESS INFORMATION .k//A ADDR S 1 NEAREST CROSS S REET ✓34 to irdirzte PARTNERSRIP ❑ STATE AGENCY Jw S / A /- ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDEMLAGENCY [J L/'v ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME r STATE ZIP CODE SITE PHOVE#,WITH AREA CODE TYPE O BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID p If of TANK's TYPE STATION 3 FARM 5 OTHER RESERVATION or AT THIS SITE 0� ❑ ❑ TRUST LANDS ❑ JQ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRSTI PHON N WITH AREA CODE DAYSNAYE(LAST,FIRST) PH NE#WITH AREA CODE ?� 6 -orz� Y14 m NIGHTS'S N E( ST,FIRST) PHONE#WITH AREA CODE NIGHTS. AME(LAST,FIRST) PH NE 4 WITH AREA CODE A A S/ II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME. 0�✓''� p CARE Of ADDRESS INFORMATION RE TA DREU -V Box loiridicate El PARTNERSHIP ClSTATE-AGENCY /^1 ZL ❑J2ORPORATION 1:1 LOCAL-AGENCY ElFEDERAL-AGENCY MAILING or ST '•// ` • ET INDIVIDUAL ❑ COUNTY-AGENCY CI TYN Mv�J STATE ZIP ODE� 0 PHONE p. ITH 'Z-1 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) 33 OO��jj NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to mclicate ❑ PARTNERSHIP Cl STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. if. ❑ 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 M JURISDICTION N AGENCY IF FACILITY ID k R of TANKS at SITE CURRENT LOCAL AG CY FACILITY ID N APP ZSY NAY PHONE M WITH AREA CODE 5191 PERMIT NUMBER (J/, PERMIT11PP OVAL D_ATfi P RMIT 9XPIRAriON DATE LOCOATI'OR/}CODE CENSUS U O 3 SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED NO DATE FILED 1; ln CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY./— b FORM A(3-2-88) • 0 DATA PROCESSING COPY J