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STATE OF CALIFORNI10 WATER RESOURCES CONTRAROARD a tx`"""' { FORM A: UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE INFORMATION and/or PERMIT APPLICATION ° 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE ")FCR � MARK ONLY ❑ I NEW PERMIT F13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CO FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 1 cO T Ok*tuto ADDRESS i� EAREST CROSS ST EET ✓Bm minb ❑ PAWNERIMP ❑ STATE-AGBICY ❑ CDRPOM110N ❑ LOX AGDO ❑ RDENLAGENLY # (/�/` ❑ INDMDUAL ❑ COUNTY#GENCY CIN NAME �c STATE ZIP C E /� SITE PHONE N,WITH AREA CODE V ACA �I/A/ TYPE OF BUSINESS: 2DISTRIBUTOR4 CESSOR ✓Box itINDIAN EPA IDN INI _ #of TANK'S ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDSO' ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE sd)L k �9 IA/, NIGHTS: NAME(LAST,FI T) PHONE N WITH AREA_ CODE NIG T$: NAME(LAST,FIRST) PHONE N WITH AREA CODE 67 v!� 11. PROPERTY OWPIER INFORMATION &ADDRESS—(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓BoxCO to indicate ❑ P Tn2-- 111. ❑ STATE-AGENCY ❑ CORPORATION ❑ CALAGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL COUY CITY NAME .. / STATE ZIPCOdePH ,WITH AREA CODE TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) ICJ6 NAME ^ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY /' ❑ CORPORATION CILOCAL-AGENCY ❑ FEDERAL-AGENCY y I/V y�✓(7 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME / STATE ZIP S 74 PHON�,WITH AREA COD= IV. LEGAL NOTIFICATION AND BILLING ADDRESS (/ 91 CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 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 CrnNTY# JURISDICTION N AGENCY# FACILITY ID# #of TANKS at SITE L-� I d U 1 1 1 101010101 CURRENT LOCAL AGENC F CILITY IDN LED"CYONA PHONE#WITH AREA CODE ©xf3M0/Zf PERMIT NUMBER PERMIT APPROVAL DATEXPIRATION DATE LOCATION CODE CENSUS TR N SUPERVISOR•DISTRICTS PLAN FILED LEEtAY I 0 � �1 ,nYES NO CHECK,## PERMIT AMOUNT SURCHARGE AMOUNT RECEIPT If THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) . 0 G DATA PROCESSING COPY /)