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STATE OF CALIFORNI'jor WATER RESOURCES CONTR[R'bOARD ar•�e�~^�sA FARM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' COMPLETE THIS FORM FOR EACH FACILITY/SITE r Cq{rFO Pµ' MARK ONLY 1 NEW PERMIT F] 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 01 10 I. FACILITY/SITE INFORMATION &ADDRESS -- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N ! C N ft N ADDRESS REST CROSS STREET ✓g ffo mdicale ❑ PAR'NERSHP ❑ STATE-AGENCY 00 C Ul'CCRRWT.()N ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 'NDIVIDLAL Cl C'%NTY-AGENL'i CITY NAME STATE ZIP COPE I SITE PHONE#,WITH AREA CODE Ta CA q SZO�— r 2coq 4(_o L4- 2�? TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz if INDIAN EPA ID k #al TANK'a RESERVATION or ❑ 1 GAS STATION 1:13 FARM OTHER TRUST LANDS ElAT THIS SITE o EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST PHONE#WITH AREA CODE t>A-f3-66. Vick( 2 Lei NITS' TS' NAME(LA ,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WETH AREA CODE f - 6 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 5 L> MAILING or STREET ADDRESS ✓Box to rndicate ❑ PARTNERSHIP ❑ STATE-AGENCY C ST� �1 ❑S�RPORATION L3LOCAL-AGENCYQ FEDERAL-AGENCY INDIVIDUAL —_ El COUNTY-AGENCY CITY NAME STATE ZIP CODEPHONE#,WITH AREA CODE C III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION l 't MAILING or STREET ADDRESS ✓Box to mdicale ❑ PARTNERSHIP ❑ STATE-AGENCY RPORATION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY _ 2 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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: 1. 11. III.L-P THIS FORM HAS BEEN COMPLETED TINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT APPLICANT'S NAME{PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY FPERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE lol 0 o z o0 LOCAL AGENCY FACILITY IDM APP DYED BY NAME PHONE#WITH AREA CODE Z� PERMIT APPROVAL DATE PERMIT EXPIR TION DATE CENSUSTTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OOAAT FILED (,�/YES ❑ NO O Z CP�CS C�PERMIT AMOUNT SURCHARGE AMOUNT EF67- ODE 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 ON FORM A(3-2-88? - DATA PROCESSING COPY