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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD /s<` "^ FORM'A'-a_ m SITE UNDERGROUND STORAGE TANK PROGRAM iie FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° a COMPLETE THIS FORM FOR EACH FACILITY/SITE �"'��°-"-'" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMA NTL ED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE TIM I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE}gAME CAREOF DURESS INFORMATION , 1 ADDRES �I rr ^ NLARIATGROSS STREET x`Bol to i�Nrsle ❑ PARTNERSHIP ❑ STATE AGPID � �t_/ / / ❑.2GAPGRATIGN ❑ LOCAL-AGENCY ❑ FEDERALAGPILY / ('J V INDIVIDUAL ❑ CAUNN AGEI��NNCpppYppp��F CITY NAME /1y�1 STATE ZIP ODE TE PHON � rCSA Z Z33 // G CA J TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR Box if INDIAN EPA ID p RESERVATION or #of TANK'a ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. VA (LAST,FIRST)_ PHONE#W TH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME FLAST IRST) PHONE S# ITH AREA CODE NIGHTS, A ll ME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPE TY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) //Nt NAME I CARE OF ADDRESS INFORMATION MAILIq ST EET ADDREISSIOX to indicate 11PARTNERSHIP 11 STATE-AGENCY ❑ POIDRATION ❑ LOCAL-AGENCY L2FEDERAL-AGENCY V✓A' INDIVUAL ❑ COUN Y-AGENCY CITY NA E STATE ZIP CODE• PHONE#, ITH AREA CODE Cam C 4 9 36 S8-� III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION A MAILING or STREET ADDRESS ✓Box to indicate Q PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY Cl INDIVIDUAL Cl COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N,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. II. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY41 JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE FS = = 10101441= [01010101 CURRENT LOCAL AGENCY FACILITY ID Of APP OVED BY PHONE#WITH AREA CODE G/' (/J�/ PERMIT NUMBER PERMIT APPROVAL DATE FIERMIT EXPIRATION DATE LOCA N CODE I CENSUS TRACT# SUPERVIS fl-D ICT CODE BUSINESS PLAN FILED ATE FILED 1 7j". 32 VES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Of 11 1 1 THI FORM MUST ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. �pl (3-2-88) lY' J �Q� DATA PROCESSING COPY �./