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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD zr ;"" +` FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE n/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -m ,; � o -�T COMPLETE THIS FORM FOR EAC FACILITY/SITE `'r�Foaa" MARK ONLY F-11 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION F-] 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - Cn I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) m FACIUTYXE NAME CARE OF J ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Gm to xiome 0 PAWNEHSHIP 0 STATEAGENCY $6�G �• /'0 �s ❑ CCIPCRATID4 0 LGCAL-AGm 0 FEDERAL AGENCY 0 IILDMOIIAL 0 CD.N7-AGENCY CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE 4 CA 9s23G TYPE OF BUSINESS: ❑ TRIBUTOR [_14 PROCESSOR ✓Box if INDIAN EPA ID # RESERVATION or a of TANK's ❑ 1 GAS STATION Lff 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAM e o< CARE OF ADDRESS INFORMATION � MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAM qq CARE OF ADDRESS INFORMATION 4S MAILING or STREET ADDRESS ✓Box to indicate 1:1 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME 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: I. U. ❑ Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION a AGENCY# FACILITY ID R a of TANKS at SITE 0 CURRENTCAL AO CY FACIE. Imo#_ '/'y APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER KK JTSPERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE I CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO ❑ /y/ c CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 16 17t 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(3-2-8B) DATA PROCESSING COPY