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STATE OF CALIFOR*A WATER RESOURCES CO AL BOARD FORM `A" UNDERGROUND STORAGE TANK PROGRAM `—opl`P �o Z SITE FACILITY/SITE,,IN FORMAT IRONDand/or PERMIIT APPLICATION to TE THIS 7 PERMANENTLY CLOSED SITE m) ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �✓ 00 ❑ 1 NEW PERMIT ❑6 TEMPORARY SITE CLOSURE MARK ONLY ❑q AMENDED PERMIT ONE ITEM ❑ 2 INTERIM PERMIT 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) CARE OF ADDS INFORMATION C ^ FACILITY ITE NAME j ` n ' I (`(` 'I�( t� O W,L NEAR CROSS STRE T BwlolMiWe Cl P SHIP ❑ SiAiE-AGFNCi' ✓ � �t ❑ conPoaAiloN �I.ACENLY C3rEOEaai AGENCY ADDRESS `.. GJ 0 INGNIGUAL 0 WUNlY AGENCY L4 o i n m Z GSa Ll o GIzo9 WITH o STATE CITY NAME CA ( EPA ID a MOI TANK'# 7� I ❑4 PROCESSOR ✓Box it INDIAN v TYPE OF BUSINESS'. ❑2 DISTflIBUTOR AT THIS SITEEl I GAR STATION 3 FARM RESERVATION or ❑ ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(SECONDARY) PHONE N WITH AREA CODE EMERGENCY CONTACT PERSON(PRIMARY PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) DAYSNAME(LAST.FIRST) j-v 57 t)5 PHONE A WITH AREA CODE U.h I t eralu� PHONE p WITH AREA CODE NIGHTS: NAME(LAST.FJ95x) NIGHTS: NAME(LAST, IRST) — 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) INF CARE OF ADDRESS ORMATION NAME E ( JT ✓Box to indicate Cl PARTNERSHIP Cl STATE-AGENCY MAILING or STRE T ADDRESS 0 CORPORATION $LOCAL-AGENCY G FEDERAL-AGENCY , Cl INDIVIDUAL 0 COUNTY-AGENCY STAly Zip COUOUL ( ( , PHlIONE p,WIT�(H ARE'AyCODE CITU NAME ylYi,'-�', l`-^' `i v 4L ✓�✓ �� U ('O(�1 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME t'� WS to intlicate 0 PARTNERSHIP 0 STATE-AGENCY MAILING or STREET ADDRESS 0 CORPORATION ❑ LOCAL-AGENCY E3FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE p,WITH AREA CODE CIN NAME 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.el- 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) -_ LOCAL AGENCY USE ONLY FACILITY ID# It of TANKS at SITE JURISDICTION# AGENCY# `f I PNONE#WITH AREA CO DE APPROVED BY NAME CURRENT LOCAL AGENCFA CILIT'10 It D q0 PERMIT EXPIRATION DATE PERMIT NUMBER PERMIT APPROVAL DATE GATE FILED r BUSINESS PLAN FILED G CENSUSTRA # SUPERVISCgST"q CODE YES NO LOCATIQN E BY: �v` FEE CODE RECEIPTp CHECK# PERMIT AMO NT SURCHARGE AMOUNT THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'Br APPLICATION(S), UNLESS 714Is IS A CHANGE OF SITE INFORMATION ONLY. / FORM A(3-2-88) " DATA PROCESSING COPY