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STATE OF CALIFORNI11 WATER RESOURCES CONTROROARDOF FORM A: UNDERGROUND STORAGE TANK PROGRAM m�" SITE [_(� I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITEIna MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑'MANGE OF INFORMATION ❑ 7 PERMANENTLY C4LqEQ.SaE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 4 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) WV. FACILITY/SITE NAME CARE OF DRESS INFORMATION d, " ('�a . ADDRESS 1 NEARE CROSSST{IEET ✓BMIOrvkab 13PARTNERSHIP ❑ STATE-AGENCY 10D AJ 0 i�//-µms, ❑ 0owmTION ❑ lO 43ENIN EAAL FNIN ❑ INDMCUAL 0 CWN1Y-AGENCY CRY NAME STATE ZIP ODE PHO N,WITH AV(`ADEM TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 P ESSOR ✓Bo%#INDIAN EPA ID# S OA/ ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION or #of TANKY ❑ TRUST LANDS ❑ AT THIS SITE (/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGEkCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRSJ) , PH NE Jr WITH AREA CODE DAYS: N E(LAST,FIRST) P ONE H WITH AREA CODE NIGHTS: NAMEILAST,FIRST) PHO If MTH AREA CODE NIGHTS: AME(LAST,FIRST) P NE#WITH AREA CODE s S 3 � sQ 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION GIMn/ S 14 MAILING or STREET AD RESS _ ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY CORPORATION 0 LOCAL-AGENCY DER ENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY C r3ME& STATE ZIP CODE / / PHON N,WITH AREA CODE lVk0 III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME ^^ CARE OF ADDRESS INFORMATION MAILING or STREET A DRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ N. in.❑ 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# JURISDICTION# AGENCY# FACILITY ID# #o/TANKS at SITE 01 U 10 1 1 CUflflENT LOCAL AGENCY FACILITY IDN APP ED Y A E PHONE WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRApC�T# SUPE OR- (STRICT CODE BUSINESS PLAN FILED DA FI 3 o v YES NO / CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 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. 1 / FORM A(3-2-88) • ) 1U1-_J DATA PROCESSING COPY