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STATE'OF CALIFORNIA- WATER RESOURCES CONTRO"OARD FORM;"A,�( �. „ UNDERGROUND STORAGE TANK PROGRAM ® �o SITF FACILITY/SITE, INFORMATION and/or PERMIT APPLICAT COMPLETE THIS FORM FOR EACH FACILITY/SITE MAR ONLY 1 NEW PERMIT � 3 RENEWAL PERMIT CHANGE OF INFORMATION Y CLOSE ITE ONE M 2 INTERIM PERMIT 1 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/S INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME C D B CARE OF ADDRESS INFORMATION JCTW NEAR/FAST WS STRE�EJT ✓BarbYd 11 TI D PAwNEFSHitoox-Kp ❑ FERESTATA EPCY AGE ADDRESS Lf � ^ 1•� L ST C/ r " S/ ❑ INDMDUALI� ❑ IG NMIY-AGENGY ❑ RDERII PGENC/ CITY NAME V I STATE ZIPCODE SITEPHONE WITHAREACODE CA S36 - �3-267 TYPE OF BUSINESS'. Q 2 DI UTOR Ej 4 PROCESSOR ✓Box if INDIAN EPA ID # N of TANK1 RESERVATION or ❑ AT THISSITE I GAS STATION FARM 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAM {LAST,FIRST / PHONE p WITH AREA COpE DAYS:-NAME FIRST) PHONE p WITH AREA CODE �l 0 0�1 3 S=ZG b NIGHTS'. NAME(LA ,FIRST PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ' /'f /— /� � CARE OF ADDRESS INFORMATION MAILING or STREET ADDDRESSS,rr"11//"YY_ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY q D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME ,/7 STATE ZIP CODE PHONE p,WITH AREA CODE r/ S 3a III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ^ J CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS J\ /L ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVI ADBIIISS 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID R N of TANKS St SITE m / 16 16 1 101 (0a0 CURRENT LO _ENCY F CIL??)q1/ APPROVED BY NAME PHONE N WITH AREA CODE 5 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATI/O�N DE CENSUS TRACT• SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DATE FILED 4ONL .YES E] NO E]PERMIT AMOUNT SURCHARGEA OUNT FEE CODE RECEIPT# BY:THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMAT U/I FORM A(3-2-88) J