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r oma. STATE OF CALIFORNI9 WATER RESOURCES CONTRAINIOARD W FORM `A': UNDERGROUND STORAGE TANK PROGRAM =" o SITE I / Y l FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° I ; �(' COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERM LOSED n ONE ITEM ❑ 2 INTERIM PERMIT El4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -�. L FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) L FACT E N ME CARE OF ADDRES INFORMATION A ADORES NEAR CRO STREET ✓B bnarak ❑ PAUNE�IIP ❑ STATE AGENCY N IAYfANPOPATION ❑ LOCAL-AGENCY ❑ FEOE' AGENCY 00 .v ❑ INDIVIDUAL ❑ COUNIY AGENCY A CITY NAME L.�V al f STATE ZIRLODE SI E PH E:k,WITH AREA CODE (A TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑ 4 ROCESSOR ✓Box if INDIAN EPA ID p /C/�G)/ IfofTTANNKK's ❑ I GAS STATION 3 FARM 5 OTHER RESERVATION or ,/ ,A /{ ❑ TRUST LANDS ❑ Yr 1`N AT THIS SITE(/� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME S FIyJ RSTj <y', _ /� �NE�WITH AREA CODE DAYS: ry4ME(LAST,FIRST) PHONE q WITH AREA CODE NIGHTS: AME(oGLAA[ST`,FIRST •LL�f-/(•/""`O(�Z PHONE N WITH AREACODECOODE NIGHTS:. AME(LAST,FIRST) PH E#WITH AREA CODE A d 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME P CAREOFADRESSINFORMATION 64 MAILING or. TREET ADDRESS ✓ IO Indicate 11 PARTNERSHIP ElSTATE-AGENCY S CORPORATION 11LOCAL-AGENCY 11FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAM STATE ZIP CODE PHONE N.WITH AREA CODE SA III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or S EET ADDRESS ✓$W x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY tTCORPORATION ❑ LCCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAM STATE ZIPCODE PHONE 4,WITH AREA CODE A IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. pr it. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY p FACILITY ID p ir of TANKS at SITE ® = = 1010W311 CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE p WITH AREA CODE 1J H2-1 D PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHEK ODE CEN US TR SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED ILED / 161 VES NO iv PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p 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. FORMA(3-2-SS) DATA PROCESSING COPY