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.STATE OF CALIFORNIIA WATER RESOURCES CONTROL BOARD EE r.Kdy( FORM `A': UNDERGROUND STORAGE TANK PROGRAM AU SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICfiETjjpqP LTI � COMPLETE THIS FORM FOR EACH FACILITY/SITE PERMIT/ ES MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q r I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ap FACILITY/SITE NAMECm I—� �� CARE OF A�RESS INFORMATION I r 6�. Nc�n� Mrd C �� 30 ADDRESS '/ NEAREST CROSS STjjREEET -/Box to indicate PARTNERSHIP ElSTATE-AGENCY90El LOCAL-AGENCY C)D U n urn ❑ NDIIVIDUALIDN ❑ COUNTY AGENCY ❑ FEDERAL-AGENCY CITU NAME�'� STATE Z'�CO�E_�� SITE PH NE#,WI�AR�CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # `LGf�J`C��) j(�(]//� GAS STATION 3 FARM 5 OTHER RESERVATION or `^�)� �? #of TANK's q ❑ ❑ TRUST LANDS ❑ � f �L/ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS- NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIR T) �� PHONE#WITH AREA CODE HTS- NAME AME(L I.FIRST) � I` � �C��D )E��AREA;ODE 7 7- \) -- II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETEb) NAME CARE OF ADDRESS INFORMATION Co MAILING or STREET ADDRESS ✓aw to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ElLOCAL-AGENCYFEDERAL-AGENCY - I LL �� 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITRME STATE ZIP CODE f HONE#,WITH AREA CODE r() C 32-30 2--02 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ' L72 Y)C m e— MAILING or STREET ADDRESS ,_✓ x Lo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY �� ,1 ' �In ' Lj� UYCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY /V /I `J ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME r a STATE 1932-30 l(Xq)592_-0:2_L41 PHONE# WREDEIV. LEGAL NOTIFICATION AND BILLING ADDRESSC 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE [= I CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. FORM A(3-2-88) DATA PROCESSING COPY