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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': ,1 UNDERGROUND STORAGE TANK PROGRAM JUL SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION /a 11 C/ COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION PERMANE LY CLOSED SITE IN ONE ITEM p INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cl V I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) C C FACILITY/SITE NAME L s�hC CARE OF ADDRESS INFORMATION 12 , M A V ADDRESS q ( NEAREST CROSS STREET B.to 1 11 PARTNERSHIP 11 STATE AGENCY 2 2 5 S n/�/ 13 11 Ll LOCAL AGENCY 11FEDERAL-AGENCY V V ❑ INDIVIDUAL Cl COUNTYAGENCY CITY NAME �� STATE ZIP CODE SITE PHONE#.WITH AREA CODE CA 8Z TYPE OF BUSINESS: ❑ p TRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID # ❑ RESERVATION or #of TANK'e 1 GAS STATION 3 FAflM 5 OTHER TRUST LANDS ❑ 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,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE I.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ II. ❑ 111.❑ 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# FACILITY ID It It of TANKS at SITE mom = I I I W-) 6 -v CURRENT LOCAL AGENCY FACILITY IE9# APPROVED BY NAME PHONE If WITH AREA CODE ^ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE V1^ LOCATION CODE CENSUS TRACT# � / SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Z v YES NO 3 C \\ CHECK PER A OUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST)OR MORE TANK PERMIT FORM B'APPLICATION(S), I) S THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) DATA PROCESSING COPY