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STATE OF CALIFORNIi _ WATER RESOURCES CONTROL BOARD �—pF e� r :a Wim. •;JA FORM `A': UNDERGROUND STORAGE TANK PROGRAM "moo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION J( - COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D I I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION UAJ/ ll PDD 5-1—OKC— IVC H- ADDRESS NEAREST CROSS STREET ✓Bax to Wicale ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 5• W I D l lJ I,V/T ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE StoGf<�U� CA TYPE OF BUSINESS: p DISTRIBUTOR 0 4 PROCESSOR ✓Box if INDIAN EPA ID a of TANK'S RESERVATION or N n ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS El AT THIS SITE `7 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE C L i s L,L VJ'Ikt- U9 -1&; SCI✓rnC- II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION &TIC CIU-IRL-.0 MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY /� /� 7� J / ❑ CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY Dt� Ll?,O` /7 S /'ULW�S 11INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE CAL 11115 57 i III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION C 0 � v� MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ElSTATE-AGENCY F Q ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ✓U 1 13INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE SA/ m 14 - 0 g IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ Ill. ©� 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 tY JURISDICTION M AGENCY N FACILITY ID S M of TANKS at SITE ED j EI I 1 16, 1 (-) F/ I � 16,) 1:1 L I 67c, T71 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE / cvA0I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION/CODE CENSUS TRACT N %%''11 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (/ 1 ov __9 YES NO / Z 7 0 CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: 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 ` FORMA(3-2-88) \\V`7 $r