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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "e I f FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FA ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE Fi ONE ITEM ❑2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) —4 4 FACILITY/SITE NAME. ` CARE OF ADDRESS INFORMATION /Res cc /Ur ADDRESS c ' NEAREST CROSS STREET ✓Bw to ❑ PARTNERSHIP ❑ STATE AGENCY 3.3/ /V, 9!//"U I"G p!X' . ❑ omlDwiloN � �Nu nACENC ❑ TEDEHALacgacr CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE �fp fah CA 9s� v�-- av51V(0 5"BGG 7 TYPE O USINESS: ❑ 2 DISTRIBUTOR ❑/PROCESSOR I -/Box It INDIAN EPA ID a I GAS STATION 3 FARM 5 OTHER RESERVATION or �7 M of TANK'3 E] ❑ TRUST LANDS ❑ atIc- ooO / 9573 AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA E(LAST.FIRST) PHONE X WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE k WITH AREA CODE S�o6ru NIGHTS. NAME(LAST.FIRST) PHONE a WITH AREA CODt NIGHTS: NAME(LAST,FIRST( PHONE N WITH AREA CODE /( l ( /7 / t II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION hu lis S�o6ra L) yl S 6/v MAILING or STREET ADDRESS ✓gox to' tate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ C ORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION U MAILING or STREET ADDRESS ✓Box abate ❑ PARTNERSHIP ClSTATE-AGENCY ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL Cl COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE p,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. I. ❑ 111.❑ 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY R FACILITY ID N R of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IO K APPROVED BY NAME PHONE N WITH AREA CODE RL s3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 1 )CATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED ❑ DATE FILED �� 7 31 YES NO CK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: (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 (3-2-98) / Now DATA PROCESSING COPY `+�