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STATE OF CALIFORNIlr- WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM m" SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMAN�ENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT 1:1E 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / I I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILI /SITE NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ADDRESS �` yy � I l'I•-V-- 1 , NEAREST CROSS STREET ✓Bmm Mole ❑ PARTRERGHIP ❑ STATE AGENCY ❑ C4RR7MTION O LOGIAGENLY ❑ FEDEIUL AGENCY ❑ INDMWAL O CWNIY-AGENCY CITY NAME , /I STATE CA ZIP CODE SITE PHONE N, WITH AREA CODE dao S TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ❑1 GAS STATION [p /3 FFARM 5 OTHER U✓ ❑ ✓ Box it INDIAN RESERVATION or TRUST LANDS ❑ EPA ID N CENSUS TRACT t of TANKY AT THIS SITE O EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS' NAME (LAST, FIRST) PHONE N WITH AREA CODE Farr Cur ✓Yl. ��09 587-33 DAYS. NAME (LAST, FIRST) PHONE p WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE N WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME , CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILING or STREET ADDRESS %/ Box to indicate O PARTNERSHIP ❑ STATE -AGENCY BY NAME PHONE N WITH AREA CODE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE N, WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME c CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CURRENT L AGENCY FACILITY IDNAPPROVED L 3 3 ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY BY NAME PHONE N WITH AREA CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME $TATE ZIP CODE PHONE N, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVB 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 R = JURISDICTION R = AGENCY R = FACILITY ID S N of TANKS N SITE I 10y71Od CURRENT L AGENCY FACILITY IDNAPPROVED L 3 3 BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT SUPERVISOR-OIS CT CODE BUSINESS P S N❑FILED NG ❑ DAN 7 �V �.yz PLOCATIOH�CODE PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT • BY THIS FORM MUST BE ACCOMP #D Byyy��(((}``��jjj```EAST (1) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY,5 F��OR%% A (3 -2 -RS) \ 'L