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STATE OF CALIFORNtx WATER RESOURCES CONTROrCBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH 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 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDREfS2 /.1� /„-� 14 i-imni 61 /` NEAREST CROSS STREET ✓5tabrbuwwmukl, 0 PAITIERGW 0 STATE AGENCY c J 2 V t , �} I/_ , O CORPORATION ❑ LOMAGENCY AGENCY ❑ FEDERAL-AC•ENGY CITY NAME (�� 1 ,�/7 STATE ZIPCOOE �O SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS. ❑ 2 DI OR ❑ /PROCESSOR ✓Box if INDIAN EPA ID M RESERVATION or If of TANM' ❑ 1 GAS STATION 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 ILAST.FIRST) PHONE F WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boa to i00icate 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boa tointlicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOYB ADORBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION* AGENCY R FACILITY I N of TANKS at SITE � 9 0 107 CURRENT GENCY FACILITY ID APPROVED BY NAME PHONE F WITH AREA CODE � 3 PERMIT NUMBER IPERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# E CENSUS TAAC SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NO ❑ DATE FILED PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M (/p BY:/ 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 ON FORMA(3-2-88) �� J1