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or . STATE OF CALIFOR WATER RESOURCES CONTS BOARD u: l FORM `A': UNDERGROUND STORAGE TANK PROGRAM m , SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �4l�IORN�P COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT Fl 3 RENEWAL PERMIT 10 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM El 2 INTERIM PERMIT 04 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CAPE OF ADDRESS INFORMATION , S .As L/efi Ceti�er SfPU5 NEAREST CROSS STR T loiiticck ❑ PARTNERSHIP ❑ STATE AGENCY ADDRESS ,1 h fif W COWDItATON ❑ LOCA.AGENCY ❑ FECERALAGENCY yBoU A-I l' f �k NO IOUA ❑ CORN -AGENC CITU NAME STATE ZIP CODE SITE PHONE p.WITH AREA CODE S- cr aA CA gs"2Ota TYPE OF BUSINESS'. 2 01STRIBIfTOR 4 PROCESSOR ✓Box if INDIAN EPA ID N N of TANKY 5 OTHER RESERVATION or AT THIS SITE Fj 1 GAS STATION 3 FARM TRUST LANDS El EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) PHONE Al WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) A lzz4Pve_ r/�O`7-17?Z —/550 PHONEN WITH AREA CODE NIGHTS' NAME(LAST, RST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to Indicate [I PARTNERSHIP ❑ STATE-AGENCY CORPORATION A ❑ COUNTY-AGENCY AGENCYPORTION ❑ FEDERAL-AGENCY El ND STATE ZIP CODE PHONE N,WITH AREA CODE CIN NAME Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box m indicate ❑ PARTNERSHIP EISTATE-AGENCY ❑ CORPORATION Cl COUNTY AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL STATE ZIP CODE PHONE N,WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY IUSEE ONLY IYY pz;2 JURISDICTION AGE�� FACILITY IDM N of TANKS At SITE •. / 5 0 9 CY FACILITY IO N APPROVED BY NAME PHONE N WITH AREA CODE P9NJy8PERMIT APPROVAL DATE PERMR EXPIMTION DATE CENSUS TRACTM SUPERVISOR-DISTRICT CODE BUSINE88PS FILEDNOo23.�sC3 3.Z5I 'PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM B�I I I 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 ON FO A(3-2-58)