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i STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "f FORM A: UNDERGROUND STORAGE TANK PROGRAM " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION _ ; COMPLETE THIS FORM FOR EACH F ILITY/SITE `+.�,o _., 1 a MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERWNENTLY CLOSED SITE (may ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O. I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) o, FACILITY/SITE NAME ADDRESS CARE OF ADDRESS INFORMATION L 71i/ n/7A t, e NEAREST CROSS STREET ✓ Bab Nlo0 OL E 0 AGENCY G55i vO GONPOM FmRW.AGENCY ROrvwxCm NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE 336 o I - TYPE OF BcA 23 —OZD BUSINESS: CA DISTRIBUTOR ❑4 PROCESSOR ✓ ❑ Box if INDIAN EPA ID x ❑ 1 GASSTATION Ej3 FARM 0 5 OTHER TgUSTYLANDS of ❑ N of TANK'# 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 p WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE Of ADDRESS INFORMATION MAILING w STREET ADDRESS 1/80.to indicale 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY CIN NAME ❑ INDIVIDUAL Cl COUNTYAGENCY STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓Box to intlicele ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY CITY NAME ❑ INDIVIDUAL 0 COUNTY-AGENCY STATE ZIP CODE 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. ❑ 11. ❑ 111,❑ 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 K JURISDICTION Y AGENCY R FACILITY ID If TANKS sl SITE = ® ods d CURRENT LOCAL AGENCY FACILITY ID• DDS -7 N7 -7 BY NAME PHONE N WITH AREA CODE � PERMIT NUMBER PERMIT APPROVAL DATE 5FEECODE FRECEIPT# LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE DATE FILED p 2 3 y0 3 ZbNO //—Zz�/ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT BY:6t)45 THISpORY MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FOflM (3-2B8) A/ _. DATA PROCESSING COPY .,�.