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_( 56^tvOy TSR STATE OF CALIFORN& WATER RESOURCES CONTROL BOARD e A FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SIT�� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE "1Op"�P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PE YCLOSEDIm SITE ONE ITEM ❑Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 771 Ln V I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF A DRESS INFORMATION A ADDRESS N ST CROSS STREET ✓ SrAEl PARINEASMP ❑ STATE-AGENCY I w//�� / ❑ TION ElLOWAGENCY 1:1FEDEMLAGENC/ V IB�NDNIDUAL ❑ CWNTY AGENCY CRY NAM STATE ZIP OD SITE PHO.F N.WITH AREA CODE CA TYPE OF BUSINESS. DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA IID a R of TANK'S ❑ 1 GAS STATION FARM 101 ❑ 50THEH TRAT USTYLANDS ar ❑ /✓ /v AT TNIS SITE D EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAyt(LAST,FIRST) PHON ITH AREA CODE j/J S NIGHTS: ME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHT VA 11. FIRST) PHO # ITH AREA CODE S A II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME S CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 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 Y1 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE DECODE PHONE#,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. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE m1010 111 )__ I s19 1 112 10 10D CURRENT LOCAL AGENCY FACILITY ID# APP O EO[/G By NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIlfEXPIRAjION DATE LOC ODE CENS'ZSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED R� 5 YES NO j !/X CHI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. \ \\FORMA(3-2-118) ` _ J .Ot�j\\ DATA PROCESSING COPY