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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 9e" l�f l FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �" Z SITFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' to COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY F7 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOSED SITE N ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDEOPERMIT ❑6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) A FACILITY/SITE NAME CARE OF ADDRESS INFORMATION A Ad ADDRESS, , X RdNEAREST CROSS STREET ✓Borb mm [IPARINERBIIP ❑ STATE-AGOCY ❑ nON ElLOCAL-AGENCY ❑ FEDEPAL-AGBILY a I � L ❑ WUNIY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE p,WITH AR CODE L�04-111, CA i o9 -331 TYPE OF BUSINESS: ❑p D UTOR ❑4 PROCESSOR E EBooRVAT ON N EPA ID p X of TANK'c ❑ 1 GAS STATION ARA ❑5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION wI� i MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S I MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY M FACILITY ID R R of TANKS at SITE 07 bG6 CURRENT LO G[NCY FAQILITY I k APPROVED BY NAME PHONE 0 WITH AREA CODE PERMIT NUMBER / PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA ON CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS S NFILED NO ❑ DATE FILED ;Y/I� CHECK 0 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p 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. W � DATA PROCESSING COPY