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STATE OF CALIFORII IC WATER RESOURCES CONTft CBOARD �A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE Cl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FA /SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑S TEMPORARY SITE CLOSURE I.FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 4 nc ADDRESS NEAREST GROSS STREET ✓ „Sy, ❑ PMRNESbi [3SR�IE-,1GEN,Y E. Cc ❑ C3 L ICY ElFEIEW,A1844N CITY NAME STATE ZIP CODE SITE PHONE 0,WITH AREA CODE a.7 « CA TYPE OF BUSINESS: ❑2,WfABUTOR ❑4 PROCE3SOR ES m iifINDIAN EPA 10 M If oI TANKS [1) 1 WSTATION 3 FARM El OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE / '�r u n � 9'8j-080 ', ''• NIGHTS: NAME(I PfiONE M WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE It WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING arSTREET ADORESS ✓B IMicete ❑ PA lrERSHIP - ❑ STATE-AGENCY RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY l r/YJ llQ 11 STATE 11 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE let oCA _:4.6 9- 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓BOX to irMkele ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE Jr.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE AOORMSS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ NL❑ 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 B JURISDICTION Y AGENCY N FACILITY ID k B O7 TANKS M SITE " 3 q ca 1 Y os o o 1 C) I i CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE N WITH AREA CODE e ASTL ! (`b I MIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ATION CODE CENBUB TRACT B SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ,P �_(0 YES NO �CK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a BY: C \l \ 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.- FORM NLY.FORM A(3-2-88)