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STATE OF CALIFORNIV WATER RESOURCES CONTRO OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a z SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 nC9LIFOPi�P COMPLETE THIS FORM FOR EACH AGILITY/SITE — MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Iqall, CHANGE OF INFORMATION O. TLV CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE U —� 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACILITYISITE NAME ( CARE OF ADDRESS INFORMATION 5 F- lAA P-V4 s bila ADDRESS NEAREST CROSS STREET ✓Bo�laiMigle ❑ PARTNERSHIP 0 STATE AGENCY 9�Z I -5 0 AAPOAATION 0 LOCIAGEN 0 FEDERAL AGENCY J1 / Cl IN ❑ ClJUN1RAGENGY CITY NAME S-7/� / STATCA 21P CODE ZQ / SITE PHONE p.WITH AREA CODE TYPE OF BUSINESS. 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID a p(J/ 5 If o1 TANK's ❑ ❑ RESERVATION orAT THIS SITE I GAS STATION E] 3 FARM 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE A1, b A'r` 6MikZ01-V63-39 NIGHTS: NAME(LAST.FIRST) PHONE 9 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION =Z SF L MAILING or STREET ADDRESS 'n O%t0 indicate 0 PARTNERSHIP 0 STATE-AGENCY 1 1 I G CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY O 5� O STA❑ INDIVIDUAL CIZIPCODU COUNTY-AGENCPHONEf.WITHAREACODE TTU NAME 0N3A 9-10 �,^ 9 1 -- III. TANK OWNER INFORMATION & ,ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Sox to indicate 0 PARTNERSHIP 0 STATE-AGENCY I Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS FCNECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ill.❑ 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 B AGENCY# FACILITY IDM Rol TANKS at SITE F(-) O13 00 1613 CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE 51/n/ R t� S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT{,# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED D 0 O7 7j(J YES NO CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY./-iRs y 2— & THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY/ FORM A(3-2-1113) 40 (\/1 DATA PROCESSING COPY