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STATE OF CALIFORNerr WATER RESOURCESCONTkmw0BOARD FORM `A': a. UNDERGROUND STORAGE TANK PROGRAM �o SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE 'IF°II-"' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 Q I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �Oe_ A r ' n ADDRESS NEAREST CROSS STREET ✓Bab bares ❑ PAITIEBBIP [3STATE AGM 3� a I0 NW0RATION El LOCAL-AGENCY ❑ PEBEMLAGDICY ❑ IN wuk ❑ WAT(AGENC/ CITU NAME Fes• STATE 4�� JE N� CO / klo CA C TYPE OF BUSINESS ❑ p 015 IBUTOR ❑ d PROCESSOfl ✓Box if INDIAN EPA ID # A.,�' � R of TANK'# ❑ I GAS STATION FARM ❑ 5 OTHER TRUSTYLANDS oT ❑ / �m ' � AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NOA�LAST,FIRST) /w PHONE NOWITH AREA CODE DAYSNAME 3T,FIRST) PHONE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AR17)EA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME V Q CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓Box to md,cate 0 PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Boa to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. ❑ it. ❑ 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 E JURISDICTION If AGENCY M FACILITY IDR R of TANKS BI SITE F-37 q] = ami CURRENT LOCAL AGENCY FACIA ljl,# APPROVED I'NAME - /� PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE VVVPERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT R SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 9 YES NO CHECK# PERMIl AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: all 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(3-288)