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')is - 3 -Cl STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE -� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I l' I COMPLETE THIS FORM FOR EACH Fl-'ILITY/SITE OF SEP iu�iir�•.r'ti\ f' 4 W ��7 _ �0 c"al/FOR��P MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT , CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ko)" l_H R s ick CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ^^�� O'` 7 #, 43-I cr 76 CITY NAME PHONE At, WITH AREA CODE -o� ADDRESS ZIP CODE NEAREST CROSS STREET ✓ M kale ❑ PARTNERSHIP ❑ STATE -AGENCY N PERMIT EXPIRATION DATE RPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY 1 12)9q tQ . A I N ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME LOCATION CODE STATE ZIP CODE SUPERVISOR -DISTRICT CODE SITE PHONE If, WITH AREA CODE AN)—( cZ/1 DATE FILED �0 CA 9533(,7, aug 236) - OF (NESS: F__]2 DISTRIBUTOR F-]4 PROCESSOR I/Box ii INDIAN EPA ID a CHECK # # of TANK's ETYPE 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or TRUST LANDS ❑ FEE CODE I RECEIPT # AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE It WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE a WITH AREA CODE LA M (TeaRoo 9ac( - NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME —1h UY%Al csy.J CARE OF ADDRESS INFORMATION ko)" l_H R s ick CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ^^�� O'` ,� L, 1� ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY El CORPORATION E)LOCAL-AGENCY ElFEDERAL-AGENCY ElINDIVIDUAL ❑ COUNTY -AGENCY CITY NAME PHONE At, WITH AREA CODE -o� STATE ZIP CODE PHONE a, WITH AREA CODE nom( + PERMIT EXPIRATION DATE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME Thp, CARE OF ADDRESS INFORMATION ko)" l_H R s ick MAILING or STRFFT ADDRESS /"n — 1 �j'7' - Sujk 7 U IU fQS( Roe ) IO V5.<6 ndicate ❑ PARTNERSHIP ❑ STATE -AGENCY CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY El INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME �/ S A C)0- 0 STATE ZIP CODE PHONE At, WITH AREA CODE -o� 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 COUNTY # JURISDICTION # AGENCY # EEI FACILITY ID # rD lo r Iq 1,3 El # of TANKS at SITE 0 0 10 3 CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAMEPHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE / PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED DATE FILED �0 L_) go 4,-,y YES NO [:]D CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE I RECEIPT # IBY: 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