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STATE OF CALIFORNIA- WATER RESOURCES CONTROv-BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ACOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 PERMANENTL SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITYS,/BITE NAME CARE OF ADDRESS INFORMATION ADDRESS (\'� NEAREST CROSS STREET n ✓BmbxAok 0 PAWMM11P 0 StATAGBAN l 7 D , I / W Il� J�, r Q�C� a CgPoAA11G11 o LGLAIN AGENN I] i .AC�HCY ❑ INGMDIAL 0 LOCkNCY EOFWL CITY NAME w✓\ STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA 'zo 3 a O TYPE OF BUSINESS: ❑ 2 DI RIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N RESERVATION Gr It Of TANKY ❑ I WSIATION FARM ❑ 5OTHER TRUST LANDS ❑ AT THIS SITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE k WITH AREA CODE (J cao pL 31-ab / NIGHTS'. NAME(LAST.F RST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE S m'vk_k_ II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �- MAILINGorSTREETADDRESS ✓Box to irrc,.te 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL Cl 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 S cta/ S Y MAILING or STREET ADDRESS ✓Box to ilo.cate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD MUSED 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 APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION x AGENCY R FACILI r W K of TANKS N SITE OO 4S' 6Oo I O CURRENT LOCAL AO CILITY ID N APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TAC-T1• SUPERVISOR-DMTyAI TCODE BUBINE88 PLAN FILED DATE FIL/E�D L(-7/T 3• A a �xR J YES ❑ NO ❑ / / 90 I /C� CHECK S PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) S