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STATE OF CALIFORNI.0 WATER RESOURCES CONTRCROARD FORM `A': SITE UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION L m,.. COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEWPERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM 21NTERIMPERMIiEl 7 PERMANENTLY CLOSED SII 4 AMENDED PERMIT �6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME ieIDARE OF ADDRESS INFORMATION M ADDRESS N 1 ' 1 r �/C%✓YLL� I I� NEAREST CROSS STRE ✓gp�londdrz@ ❑ pA9INB5fIW STATE AGENCY "'I u{ `_ ❑ COWOAAiION ❑ LOCALAGBIC1' ❑ FEDERAL-AGEN 'v ' 1 CY CITY NAME - M STATE ❑ INOMDUAL 103WUNTYA INCE KJL kZIP CODE L� L)� SITE PHONE p,WITH AREA CODE TYPEOFBUSINESS: Ij 2 DISTRIBUTOR Lj/PROCESSOR ✓ nQKA Rax it INDIAN EPA ID ID p It I GAB STATION 3 FARM ISI,,,,.,,ER TRUST LANDS AT THIS SITE RESERVATION or ❑ M of TANK' L`�f�"'" EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) _ PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PunuE M WITH AREA CODE NIGHTS: NAME(LAST.FIRST) -- PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME y, CAREOFADDRES INFORMATION /I ' , 1 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP D ❑ STATECY ❑ INDIVIDUAL ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY CITY NAME ❑ COUNTY-AGENCY STATE ZIP CODE PHONE p,WITH AREA CODE (—LlxgS��. gI� S3oY933 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) -�KLjI �q 11497 NAME (KAP CARE OF ADDRESS INFORMATION �� MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP❑ CORPORATION ❑ LOCAL-AGENCY ❑ STATE-AGENCY ❑ INDIVIDUAL ❑ COUNTY- ❑ FEDERAL-AGENCY CITU NAME AGENCY STATE ZIP CODE PHONE It,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. E:j 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# JURISDICTION k AGENCY M FACILITY ID At ;PHONE 9SITOE at �� O O I R Q CURRENT LOCAL AGENCY FACILI ID k APPROVED BY NAME n^ O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE rClHECK# ION CODE CENSUS TRACT 11 SUPERVISOR-DISTBIr.T CODE BUSINESS PLAN FILED r g� ❑ ❑ DAT )LED Ul `1?I YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTx l BY: 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY WI FORMA(3$B&) • I /' DATA PROCESSING COPY 0 \\7