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STATE OF CALIFORNIA' WATER RESOURCES CONTROSOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE I C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m. o COMPLETE THIS FORM FOR EACH FACILITY/SITE "'•�?��" MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ LY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a) I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) CD I FACILfiY/SITE WAME CARE OF ADDRESS INFORMATION T4; cz Ser 0( SfA F ADDRESS !J NEAREST CROSS STREET ✓ftlrmEYak FIPARTNERSHIPEl STATE AGENCY 0 l-J{M L tONY 11 EE°EnncR�O owAON O COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE Y,WITH AREA CODE Yc +e-c� CA 9s3 /� ao� 8a3- 5 (Y TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Boz it INDIAN EPA ID a W TAWSLK1 GASSTATION E:] 3 FARM E]5 OTHER TRUST LANDS of ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ro Car 09 8a3-09 NIGHTS: N E(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION G cLc �i r MAIL/IN�G a STA ET ADJq�ESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY T7 3 S Sh �o N D r(�e ❑ CORPORATION ❑ LOCAL-AGENCY ❑ EDERA -AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY LLK CITY NAME STAtEZ9s33 PHON M.WITH AREA III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME_ CARE OF ADDRESS INFORMATION /V---0-11 aro MAILING m STREIFT ADDRESS ✓Box to indicate ElPARTNERSHIP ElSTATE-AGENCY < t ❑ CORPORATION 11LOCAL-AGENCYF DERALAG - ENCY la-35 J 1 0. O r Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE YYb nn Cad} 46336 9.1-3—09 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ IL DO III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. i APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION R AGENCY M FACILITY ID N P of TANKS at SITE 9 o 10 1 / bj 10101016 CURRENTN� ED YNC1 VPHONE Of WITH AREA CODE ff PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATI ONCENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DTE PLED 30 YES NO �j O`V CHECKPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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(3-2-90) / ^ DATA PROCESSING COPY --%