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STATE OF CALIFORNIA WATER RESOURCES CONTRANIOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE `+<,.o ,P MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO ED SIT ONE ITEM Z INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITYJ;,� NAME �, / CARE OF ADDRESS INFORMATION / L r ADDRES9 NEAREST CROSS STREET ✓BP"*AI0 0 PARTMWW 11 STATE AGBAN ❑ II71pDRATI114 El INDMIRA ZIP CODE 1,3❑ IOG.ALAG cr ❑ FEDERALAGDLY IpuxIYACDIa CITY NAME / , STATE SITE PHONE N.WITH AREA CODE c-r � CA o20 77-6.2, TYPE OF BUSINESS: p DI IROR 4 PROCESSOR ✓Boz it INDIAN EPA ID It 0 1 GAS STATION FARM 5 OTHER TRUST LANDS or ❑ YI A - Mol TANMN �W F"'�� AT THIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY : NAME(LAST FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE Al EA WITH ARCODE Cao 7 zo -oas NIGHTS: NAME(1.'157,FlRST) ONE N WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME c CARE OF ADDRESS INFORMATION MAILING or EET ADDRESS ✓BO.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY El INDIVIDUAL 13COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS —(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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: 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) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY M FACILITY ID M #of TANKS el SITE =1CLT� CL� doa moo / CUflREM LOCALAOE CY PAC IL IDN APPROVED BY NAME PHONE#WITH AREA CODE rl7i PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E%PIMTION DATE LOCATION CODE CENeUB TRACT N ^'� BUPERY180R-DISTRICT CODE BUSINESS PIAN FILED DATE FILED ] CHECK# PET A OUNT -1--- SURCHARGE UV FEE CODE YES RECEIPT* ❑ B ��/�J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `8'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) • •