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STATE OF CALIFORNIf WATER RESOURCES CONTRBOARD ^ l".A FORM `A': UNDERGROUND STORAGE TANK PROGRAM =� 4 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ! " y. COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F__] I NEW PERMIT ❑ 3 RENEWAL PERMIT lf�K CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 161 or) I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED).4A.1 ?vCJ _to[��/ w FACILITY/SITE NAME CARE OF ADDRESS INFORM 0 6L AT PS ADDRESS NEAREST CROSS STREET ✓Box to adu ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ��' ❑ INDIVIDUAL ❑ COUNTY AGENCf CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE L " CA 175-z36 - a TYPE OF BUSINESS: ❑ 2 D RIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA tD N ❑ I GAS STATION FARM ❑ 5 OTHER RESERVATION or ❑ F of TANK's TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) 1 PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NPS oD ,2 -W17-3 NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME �s CARE OF ADDRESS INFORMATION /tel/? -N I MAILING or STREET ADDR/E��5 J ✓Box to indicate 11 PARTNERSHIP ElSTATE-AGENCY 3 `�� \'+�L�j El 13 11LOCAL-AGENCY ClFEDERAL-AGENCY �� l/( �— ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE# WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BECOMPLETED)�Sg1 NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. if. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N Y r N of TANKS at SITE CURRE ENCY FACILITY ID N - APPROVED BY NAME PHONE N WITH AREA CODE 4_ PERMITNUMBER ATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS LLATE ILED/�2 v .1� -3ZS_ Y13 /0 CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR#TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THJSL IS A CHANGE OF SITE INFORMATION ONLY. .l ORM A(3-2-8g • /��VV '(v\T DATA PROCESSING COPY \` '