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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �: 'P FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITEs^",> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT �ANGE OF INFORMATION7 PERMANENTLY CLOSED SITE I"a ONE ITEM ❑p INTERIM PERMIT ❑q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ❑ rV 00 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) N FACILITY/SITE NA E CARE OF ADDRESS INF RMATIO rj r r he ( etI r,� ADDRESS NEAREST CROSS STREET Bulonkii ❑ PA ERSHIP ❑ STATE AGENCY 35 Cel"Ira I ❑ CORPO=i)N �0 LO�NAGENCY ❑ HOERAIAGENCY ❑ INBIhWAI LJ WllryrypGByCY CITY NAME _ STATE CA ZIP(]p E.�� SITE PHONE N,WITH AREA CODE (lIt acs 9-7 TYPE OF BUSINESS: ❑ 2 D IBUIOR ❑/PROCESSOR I -/Box if INDIAN EPA ID N ❑ I GAS STATION ❑3 FARM E:I ER TRUSTTESERVATION LANDS or ❑ none. If of TANK's v ATTHIS SITE no EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAM (LAST,FIRST) P NE p WITH AREA CODE DAYS: NAME(LAST,FIRST PHONE N WITH AREA CODE I I v�o S (0 Ll Y.16 NIGHTS. N E(LAST,FIR T PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE fir n du �635- 5-? i g, L�— II. PROPERTY OWNER INFORM- ION &ADDRESS — (MUST BE COMPLETED) NAMEolfq of- CARE OF ADDRESS INFORMATION MAILING or STREET AD ESS % /f I/Box lointlicale ❑� P�BINER IP ❑ STATE-AGENCY S, a c� [/-/fes ❑ CORPORATION OJ�'C CAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME ' STA ZIPCODE PHONE N,9S WITH AREA CODE ao� III. TANK OWNER IN RMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION wJ MAILING or STREET ADDRESS I/Box lointlicale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODEPHONE 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: 1. ❑ it. 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# JURISDICTION R AGENCY# FACILITY IDM If of TANKS at SITE ® = = I ol ol i I 3 4 CURRENTLOCALAOENCYFACILITYIOM APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER fn'r PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATI C DE CENSUS TRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE FILED 3.- a I YES E] NO - CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITES INFORMATION ONLY. FORMA(3-2-88) �„� DATA PROCESSING COPY �.r