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STATE OF CALIFORIprA WATER RESOURCES CONT*L BOARD a FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION d� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE z" IC I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ` NEAREST CROSS STREET ✓ idipte ❑ PAUNENSHIP ElSTATE AGENCY N xvorunGN ❑ LocAL-AGENCY 11 RDRwL�cENcr ADDRESS "J N (/A)C ❑ INDNIWAL ❑ CWNTYAGENO' W CITY NAME STATE ZIP CODE SITE PHONE#.WITHAREACODE IV r✓ CA - 31 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4PROCESSOR -/Box it INDIAN EPA ID # NoI TANK'S 1 GAS STATION 3 FARM ��THER RESERVATION or 1:1AT THIS SITE 3 [_ TRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE GeeL `� -331 5H'M E, NIGHTS: NAME(LAST. IRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION fVDAJ4/ MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ f€uER`L--AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY ✓ CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE CF) 41 2,61t N ONS III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NA E CARE OF ADDRESS INFORMATION N MAILING or STREET ADDRESS ✓ ointlicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY T.O. QUO ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AgEA CODE CA -Zoe, — IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION# AGENCY a FACILITY ID k k of TANKS at SITE [EE1 (310 lo El— CURRENT LOCAL AGENCY FACILITY ID N APPR VED BY NAME PHONE#WITH AREA CODE S5 k5f- 2Z PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE q—T ?, LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 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. FORM A(3-2-BB) DATA PROCESSING COPY �/