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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT P�T5 CHANGE OF INFORMATION ❑ 7 PER Y CLOSED SITE ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 41 z I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAM C. CARE OF ADDRESS INFORMATION F.T� 140ytm gaiEkIfU4 ADDRESS -�.,n 1 NEAREST CROSS STREET ✓Bmbidiule 0 PARTNE&P 0 STATE AGENCY' O VV I l..V�F�2/I r&2 ln) Cl I AA "" 0 CI `cAGENCY �Ac C ❑ FEDERAL acENcr CITU NAME ` STATE ZIlO W6 SITE PHONEp,WITH AREA CODE TYPE OF BUSINESS'. ❑p DISTRIBUTOR ❑ 4 PROCESSOR\✓ -/Box it INDIAN EPA ID a SS RESERVATION or N M TIS SI ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY D 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 WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ 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 R JURISDICTION N AGENCY N FACILITY IDN Mol TANKS BI SITE ml I 1 12-13961 101010 CURRENT LOCAL AGENCY FACILIW D 0 I APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK8 DE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS►LAN FILED DATE FILED / p `�. D Z. y YES NO tl �O PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPTF BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SI,UNLESS THIS IS A CHANGE OF SITE INFORMATION ON ORM A(3-2-813)