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STATE OF CALIFORNIk WATER RESOURCES CONTROLtOARD s '""'' ��, _ �" FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SITE 'W FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONm COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONPERMAM�FI yS LOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �{ 1.FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CAM/fv M05 - JArz-Y ADDRESS d /�.,�� NEAREST CROSS STREET ✓8mbrd,,,x D PMTN9&0 D STATE-AGFNLY 7 JIC////li �Z- D-irDnwu D eDNrYAGEI ❑ P�EML#CENLY CITY NAME STATE ZIP DE SITE PHONE A.WITH AREA CODE CA 36 l /o r o 9 TYPE OF BUSINESS: 1 DISTRIBUTOR 1 PROCESSOR ✓Box II INDIAN EPA ID M If of TANI ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTT LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMER91I CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE co-relrt1 BETE o9) 3G�-�ro`f NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE GHT AME(LAST,FIRST) PHONE N WITH AREA CODE CAP-reuv e ktM 36 -6t 9 II. PROPERTY OWNER INFORMATION &ADDRESS j0t EkkOMPLETED) NAME ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intliGele D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME ATE ZIP CODE PHONE M,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDR S BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to intlicele D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE IV. LEGAL NOTIFICATION AND,BILLING ADDRESS CHECK ONE(1)BOR INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ III-❑ THIS FORM HAS BEEN COM LETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAM E(P INTER A SIGNATURE) DATE LOCAL AGENCY USA ONLY COUNTY N URISDICTION• AGENCY R FACILITY ID M M of TANKS Rt SITE ° a B 7 0 0 o a CURRE/R A NCV FACILITY ID S APPROVED BY NAME PHONE F WITH AREA CODE L- PERMIT NUMBE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT F SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 a3 39O YES NO ❑ 111-VO CHECKY PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT• SY: THIS FORM MUST BE ACCOMPAI IED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON 1FORM A(3-2-BB) ��)