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STATE OF CALIFORNIf WATER RESOURCES CONTROAOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE L __7 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION { r/ COMPLETE THIS FORM FOR EACH FACILITY/SITE ac;'FORNxP, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER 16� LOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 " r^. I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/ ITE NAMECARE OF AD ESS INFORMATION tla �� ry AD RE SS / N Sj ClFOSS STREET ✓Box to indicate WPARTNERSHIP ❑ STATE-AGENCY f i El 1:1 LOCAL AGENCY ❑ FEDERAL-AGENCY ` Cl INDIVIDUAL 1:1 COUNTY-AGENCY 'x CITY NAME STATE ZIP CODE SITE PH NE H.WITH AREA CODE W /,1041 CA Zo TYPE OF BUSINESS: Ej?"2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # ❑ ❑ ❑ TRUST LANDS or ❑ A #of TANK'S / 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) D S. NAME(LAST FIRST) HONE#WITH AREA CODE DAYS: N E LAST,FIRST) PHONE#WITH AREA CODE �Pd 6 36 r-Z T?5 .4 V14 NIGHT NAM AST,FIR T) PHO E,WITH AREA CODE NIGHTS IN E(LAST,FIRST) PHON #WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE/COMPLETED) S NAME i CARE OFA D ESS INFORMATION VIA MAILING or STREET ADDRESS ✓Box o indicate (PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Lolo/ C A 1s b �� -2,7 ZS_ III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDR //S(INFORMATION /4 P W AJ J -1 MAILING or ST E� RESS ✓Box to indicate PARTNERSHIP ElSTATE-AGENCY El CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME / T :y-4 PHONE ATH 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. ❑ 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 ECURPRENT NTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE [M] I I I J I I I I I UoITToToi7_1LorToT-1— OCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE np"PERMIT NUMBER ERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSACT#� SUPERVISOR-DISTRICT CODE BUSINESSYES N FILED NO ❑ DAT IL;rjl�D�� CHECKC#/ PERMIT AMOUNT SURCHARGE AMOUNT ["13E RECEIPT# B4: 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 ONL FORMA(3-2-88) DATA PROCESSING COPY