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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD W FORM FA': m UNDERGROUND STORAGE TANK PROGRAM .0 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ila COMPLETE THIS FORM FOR EAC FACILITY/SITE 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 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME - CARE OF ADDRESS INFORMATION G1JS rJ1 rtv ADDREESS NEARECR. _�mbiNgb 0 PARMERSWP 0 SATEAGENCY 3'/S7 S. YJ CMPORA N N ❑ LOCA-400 0 FEGEML.01300 ❑ INDMDUu 0 COUNn-AGBICY CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE J CA - TYPE OF BUSINESS' ❑ 2 DISTRIBUTOR ❑4 PROCESSOR I '/Box if INDIAN EPA ID N RESERVATION or N of TANK'N ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS %/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE it 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. 1:1 if. 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 COUNTY R JURISDICTION R AGENCY R FACILITY ID R R of TANKS at SITE [L] CURRENT LOCAL AGENCY FACILITY ID N APPROVED 8Y NAME PHONE N WITH AREA CODE s1If25c�34 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ELOCATION CENSUS"ACTH SUPERVISOR-DISTRICT CODE BUSINEU PLAN FILED DATE FILEDp 32r YES ❑ NG ❑ l?a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST Ill OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88)