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STATE OF CALIFORA WATER RESOURCES CONTR L BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM W T SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I La �' COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT fn 5 CHANGE OF INFORMATION TLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE v I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NA : V A-00 F__A R$A S / CARE OF ADDRESS INFORMATION ADDRESS ' G/ NEAREST CROSS STREET ndcYe 0 PAATKE P ❑ STATE AGEIsX A)e O cawlwwlo o O tcum Amcl ❑ F OER AGExc CITY NAME STATE ZIP GOD�n A SITE PHONE q,WITH AREA COQE�t� CA TYPE OF BUSINESS: 2 DISTRBUTOR 1 PRXESSOR ✓BESEox N INDIAN EPA ID M 9 ; !�V 4 of TANK's Off/ ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUSTYLANIS ON or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MA&1NG or STREET ADDRESS ✓Boa to mdo ate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAIUNG or STREET ADDRESS ✓Boa to md,cate 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ASOVB ADDRBSS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY Y JURISDICTION M AGENCY11 FACILITY ID 0 B of TANKS BL SITE " CURRENT LOCAL AGENCY FACILITY ID 11�1]] �\ ){�A1I APPROVED BY NAME PHONE N WITH AREA CODE + l 'N(A PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCATnION( CENSUS TRACT S SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED7.. �`J YESNO PERMIT AMOUNT SURCHARGE AMOUNT FTE RECEIPT BY: , S FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY —'� I tFORM 3-2581 !/j