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STATE OF CALIFORNW WATER RESOURCES CONTROeBOARD ip FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION oCOMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2,5 CHANGE OF INFORMATION ❑ 7 P RMAN LOSED SITE FJ ONE ITEM ❑2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CA1 FACILITY/SITE NA r CARE Of ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BwlohI 0 PAWNEPSNIP 0 STATE-AGENCY 35� Ui�AG n 0 COWMTION 0 LOLL-AGENCY 0 FEDBULAGENCI ��% ❑ INOWOML 0 CIXINMAGENCY CITY NAME STATE CZIP CODE SITE PHOWITH AREA CODE A �L)��/ 835= TYPE OF BUSINESS: ❑ p P961BUTOR ❑/PROCESSOR I ✓Box ill DIAN EPA ID N RESERVATION or a of TANK's ❑ 1 GAS STATION 3 FARM E] 5 OTHER TRUST LANDS ❑ AT THIS SITE �.. EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) t PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE Ulm ,-9 NIGHTS: NAME(LAST,FIRST) pNE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME /r CARE OF ADDRESS INFORMATION 55GVwnA, MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE 111. TANK OWNER INFO MATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. E�r I. ❑ If. ❑ 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 NJURISDICTION M AGENCY a FACILITY ID M N of TANKS at SITE = = I z1 / 73 0 CURRENT LOCAL CY FACILITY ID APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER U PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TiIACT# SUPERVISOR ISTRICT DE BUSINESS PLAN FILED DATE FILED p 'L Z YES NO 6�z�'O 9 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: 1 1 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. JFORMA(32-88) - (� � DATA PROCESSING COPY `� J