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—•....'�r.+wFIRV+^`yaMb�+1PM'�''�- `I j STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD is" °,'f FORM 'A': ��s. UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m COMPLETE THIS FORM FOR EACH F CILITY/SITE C `'��eon0�" , MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ZP I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 10 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION AODRE _ NEAREST CROSS STREET nsiale ❑ PANTNERSHIP ❑ STATE#GDlL1' cc WRbMTION ❑ LXk AGENO, ❑ FEDERAL AGB w` ❑ ADIIDIAL ❑ DAINTY-AGENCY !r�i CITY NAME STATE ZIP CODE SITE PHONE p WITH AREA C DE cA aas ��i� TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BOX if INDIAN EPA ID N ❑ 1 GASSTATION E]3 FARM ❑ 5 OTHER RESERVATION or N of D TRUST LIII AT THISHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PH HE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE r NIGHTS: NAME(LAST, RST) HONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREETADORESS ^� ✓ to indicate ❑ PARTNERSHIP ❑ STATEAGENCY /plc �A CORPORATION ❑ LOCAL-AGENCY 13 FEDERAL-AGENCY (V INDIVIDUAL ❑ 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 MAILING or STREET ADDRESS ✓Boz toisficate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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: 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY N FACILITY IDN N of TANKS at SITE DE = = I DO IAPISTvl O oD CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CO4E CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED ,23 . 8'v YES NO a CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: 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. FORM A(3-2-GG) � DATA PROC°SSING COPY \J