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STATE OF CALIFORNIP WATER RESOURCESCONTRO41OARD FORM A: UNDERGROUND STORAGE TANK PROGRAM Ao SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ot COMPLETE THIS FORM FOR EACH FACILITY/SITE "'L".VY ll MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Ftr7 PERMANE CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE zz'Z2 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME {n- CARE OF ADDRESS INFORMATION -Pe.S� ADDRESS NEAREST CROSS STREET ✓BM IpiO4itl10 0 PARTNERSHIP Cl STATE AGEND ^I yA1 ` 1 I^ `n 0 CGRPORKPON 0 LOCAL AGENCY 0 FEDERAL AGENCY ItuonS s 1 /T/ 1 y% J 0 INONIOUAL 0 COUNTY AGENCY CITY NAMEAte, ik*jqYv`� STATE ZIP COD5,A O SITE PHONE It.WITH c641/ TYPE OF BUSINESS: 1012 DIST IBUiOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a 9 RESERVATION or #of TANIC# 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAM LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE CIu e -7t. NIGHTS: NAME(LAST,F ST) PHON N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME 1` CARE OF ADDRESS INFORMATION MAILING or ST EET ADDRESS ,/J`�J ✓Box to intlicale 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTKAGENCY CITY NAME STATE ZIP CODE PHONE 11,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME S/ CARE OF ADDRESS INFORMATION MAILING orS EET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE it,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDR[BB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. it. ❑ 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 N JURISDICTION 8 AGENCY R FACILITY ID If M of TANKS at SITE " CTl � � 660 � 000 10 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE D PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# 8UPERVISOR-D18TRICT CODE BUSINESS PLAN FILED DATE FILED 3 z -Nil, YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If 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 ON FORT I A(3-2-