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STATE OF CALIFORNIA WATER RESOURCES CONTROLOARD SE" rM1f W A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION e COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 10"5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE rfM I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILI /SITE NAME CARE OF ADDRESS INFORMATION o e ADDRESSIF NEAR TCROSS STREET ✓Bwbndow 0 PARTNERSHIP 0 STATE AGENCY moi'w ❑ CORPORATION ❑ LOCALAGENLY 11 FEDERAL AGENCY Al s6"l161, ❑ INDNIDUAL O COUNTY AGENp le CITY NAME^ STATE ZIP CODE ITE P�NE I ITM AREA CODE S CA 3 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID a RESERVATION or Ao1 HIS SI ❑ 1 GAS STATION E] 3 FARM OTHER TRUST LANDS ElGG/�, AT THIS SITE 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 er vn, Cao 64-513-5 NIGHTS: NAME(LAST, RST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE Of ADDRESS INFORMATION MAILING or STREET ADDRE ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY / C'', — C3 CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY . W ( (&UY L 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME±0 C STATE ZIP CODE PHONE N,WITH AREA CODE l� <s III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME e j C,6 CARE OF ADDRESS INFORMATION MAILIPor�EET ADDRESS ✓Box to,ndlcate Cl PARTNERSHIP Cl STATE-AGENCY k/LJ 0 CORPORATION 0 LOCAL-AGENCY 0 FED A -AGENCY . A 0 INDIVIDUAL 0 COUNTY-AGENCY Jie CITY NAME�1...�V STATE ZIP C05 F Ps46 p,WIYAR A CODE44 35 IV. LEGAL NOTIFICATION AND BILLING ADDRESS (� 7^ -CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A,SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION R AGENCY S FACILITY ID R R of TANKS at SITE d 10 1 1 1 1016101 CURRENT LOCAL Aj4ENCY FACILITY ID MAPPROVED BY NAME PHONE If WITH AREA CODE - Wlibfore PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION ODE CENSUS TRAC SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3A YES NO El CHI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONIS), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY, FORM A(3-2-88) J( r��c _ �L3�