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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FA ITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMAN&WkTrrMTDjITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION C IV n ADDRESS 0 I E N REST CROSS STREET ✓CIDIR TIO 0 PAAINBGB 0 KATEk 90 AGR (/ �•-%/e. ❑ Il ,ll ❑ 0011YAGENCY ❑ FlIIEAIL AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA S TYPE OF BUSINESS: ❑ 2 DISTR BIf10R ❑ 1 PROCESSOR ✓Sox if10 ESE DIAN EPA IDN N of TANWS ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS or ❑ 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 N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE PROPERTY OWNER INFORMATION &ADDRESS - (MU COMPLETED) NAME e 4 t, �� 'Tv CARE OF ADDR INFORMATION MAILING or STREET ADDRESS �` ✓Box Io indicate ❑ P ERSHIP 0 STATE-AGENCY M \ 0 CORPORATION 0 LOCAL- NCY 0FEDERAL-AGENCY (/ I ❑ INDIVIDUAL 0 COUNTY-A NCY rrNAME - ` -. STAT ZIP CODE PHON N,WITH AREA CODE 111. K OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box i - ARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS (1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El11. III. CHECK ONE ❑ 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 N JURISDICTION N AGENCY R FACILITY ID R N of TANKS M SITE 0 p I ql 61 BOO 1 / CURRENT LOCALENCY FACILITY IDN D APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUN E PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS"ACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED y YES � NO -1 CHECK♦ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: W 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(3-2-88)