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STATE OF CALIFORNIA,- WATER RESOURCES CONTRO1,.0ARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT RANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT TEMPORARY SITE CLOSURE 61 I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME p� [ CARE OF ADDRESS INFORMATION Elsle �tCCf In ! �zC�TINA ADDRESS NEAREST CROSS STREET ✓B w ❑ PARTNEFSIIP ❑ STATE-AGDO oI�vRATON o WUUMAGOId CALAGDO ❑ FFDN AGBC NIXoG CITY NAME, 1O STATE ZIP CODE 6 SITE PHONE N,WITH AREA CODE /N.Mi,�,//I h7 .J�"/jr. /c P TYPE OF BUSINESS: 15MIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID Y 8 of TANKY RESERVATION or r-1 AT THIS SITE 1 GPS STATION 3 FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE cG,f.''IElmo - D NI HTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION 8 ADDRESS — (MUST BE COMPLETED) NAME �A CARE OF ADDRESS INFORMATION 7Fl�YhP GK wG or STREET ADDRESS ✓BoxRPI RATIO ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME ^fl CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADOBBSS SHOULD BE USED FOR MOTH LEGAL NOTIFICATION AND BILLING: I, ❑ 11. ❑ 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 N JURISDICTION E AGENCY R FACILITY ID 0 8 of TANKS M SITE CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE 8 WITH AREA CODE px#3_16 PERMIT NUMBER L* L8UPEALVlW)R-DlS"ICT PPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSU8 TRCODE BUSINESS PLAN FILED DATE FI D L —'+ YES NO 6 /PERMIT AMRCNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1 FORMA(3-2-88`)1 -/'