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STATE OF CALIFORNIP WATER RESOURCES CONTRORARD �5ro"' Jk' QP'I�l A { 1 FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEWPERMIT 3 RENEWALPERMI7 S CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ��rr ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE G.. fG I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE N E CARE OF ADDRESS INFORMATION 2r. yin6eeE ADDRESS NEAREST CROSS STREET 04 �nFIRSIIF D STATE AGENCY APOUATIOND LOCAL-AGENCEl FEDEM4AGD Ct 0 INDIVIDUAL ❑ COUNTY AGENCY N CITY NAME 1 - STATE ZIP CODE SI E PHONE p,WITH AREA CODE Nr1T,Pl GRAND cA -L3 - o EPA ID NTANK1 TYPE OF BUSINESS: 2DISTRIBUTOR�1 44�,�PR�OCESSOA INDIAN RESERVATION or It HIS SITE 1 GAS STATION 3FARM MA, � n TRUSTLANDS ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE �(ov S f19 3 NIGHT AME(LAW,FIRST PHONE N WITH AREA CODE NIGHTS. NAME(LA T,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME }} CARE OF ADDRESS INFORMATION ..V MAILING or STREET ADDRESS ✓ o indicate D PARTNERSHIP D STATE-AGENCY _ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY _ (' O I ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 520 0 7 -1300 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME /i CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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. El if. D��f El 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 RLOCAL JURISDICTION N AGENCY N FACILITY ID N I R of TANKS at SITE ��CUJINNCY FACILITY IONAPPROVED BY NAME PHONE N WITH AREA CODE `_PERMPERMIT APPROVAL DATE -- PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRAL# LSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F�___ -.... YES NO ❑CHECK N PERMIT AMORCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FORMA(3-2-88) DATA PROCESSING COPY •