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STATE OF CALIFORNIP WATER RESOURCES CONTROMBOARD W FORM `A': UNDERGROUND STORAGE TANK PROGRAM �a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a COMPLETE THIS FORM FOR EACH FACT -Y/SITE MARK ONLY ❑ 1 NEW PERMIT � 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 00 00 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) w W FACILITY/SITE NAMECARE OF ADDRESS INFORMATION ADDRESSS NEAREST CROSS STREET _ ra@ D PAAINEIMP D STATE-AGENCY IPOMID 1 0 LOCAL-AGENCY 0 FEDEMLAGENCY IG2 11 Z 14,9//56,0 1A ❑ INONDUAL 0 COUNTY AGENCY CITY NAMESTATE ZIP CODE SITE PHONE N,WITH AREA CODE 'fkh CA ysozos a 6-3 7 TYPE OF BUSINESS: 2DISTAMUTOR 4Pfl R ✓BUX iI INDIAN EPA 10N #oI TANKS RESERVATION or u�L AT TRIS SI7E I GAS STATION � 3 FARM OTHFA TRUST LANDS 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 Yev.t - V 6 - 7 jr a o - V6 G-2S7f NIGHTS: NAVE(LAST ST) PHONE#WITH AREA CODE NIGHTS. AME(LAST FIRST) PHONE N WITH AREA CODE &-M71 II. PROPERTY O ER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESB ✓ o indicate D PARTNERSHIP 0 STATEAGENCY CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE s'4lgsaos - Vj 6 -31F7 III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -1,96 to indicate D PARTNERSHIP D STATE-AGENCY IV CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL 0 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. 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 COUNTY R JURISDICTION If AAIG�CYI# FACILITY ID N #of TANKS at SITE 3 9 o 1 o 'z I(? I f I I p 16C) I -�- CURRENT LOCAL AGENCY FACILITY IDM I APPROVED BYNAME PHONE It WITH AREA CODE S i9G V /a u PERMIT NUMBER PERMIT APPROVAL DATE P MIT EXPIRATION DATE [LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE YESE] NO [:] 7 PERMIT AMOUNT SURCHARGE AMOUNE D— 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(3-2-88) ` • DATA PROCESSING COPY °ORM B(c