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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD) FORM 'A': UNDERGROUND STORAGE TANK PROGRAI SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ,j 3 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 123 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION / CZ 06, Nef- t,v ADDRESS _ NEAREST CROSS STREET ✓amorrout Cl PARTNERSHIP [I STATE AGDILY cowmrim I3 CG(Y�O1T u O ND k 0 ear AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE nN CA 207 - -272 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F__] 4 PROCESSOR ✓Box if INDIAN EPA ID Al RESERVATION or Nal TANMa ❑ 1 GAS STATION ❑' 3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. ��NLLAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE CI�NCr IC 2CYa- S' - -2723 NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION I, r' MAILING or STREET ADDRESS ✓Box to inoicala 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION r MAILING or STREET ADDRESS I/Box to ind."I" 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING li ABOVE ADDRESS SHOULD BE USED FOR BROTH LEGAL NOTIFICATION AND BILLING: 1. ❑ IL ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY N FACILITY 1 N of TANKS at SITE " CU T LOCAL AGENCY FACILITY ID N ^ (� _ APPROVED 8Y NAME PHONE N WITH AREA CODE PER ll` IT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TR11CT N SUPERVISOR-D18TNICT CODE BUSINESS PLAN SLED DATE FI O -2'S, ?-0 3�;2 6 YES [:] NO Q g CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: G A) TRIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PEDMIT FORM'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-86) ��