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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ZE^` •rAe FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a Y,... o Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I� 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 W I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME (� CARE OF ADDRESS INFORMATION - ' I �U i ADDRESS NEAREST CROSS STREET ✓limb Mule ❑ PARTABIWIP ❑ STATE AGEN9 ❑ CORPORATION 1:1LOCALAGBICY ❑ FEDERAL-AGENCY ❑ INI)i ❑ CM7Y AGENCY CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE L--ID C Lam- CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a RESERVATION or II of TANK'* ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME( ST,FIRST) PHONE Al WITH AREA CODE DAYS: NAME((AST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE II 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 Be.✓ to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE II,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ .INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.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. ❑ 1L ❑ If.❑ 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 k JURISDICTION N AGENCY N FACILITY ID R R of TANKS BI SITE 3q o0 ► `t � boo � CURRENT LOCAL AGENCY FACILITY ID* 1 ^I 1 APPROVED BY NAME PHONE N WITH AREA CODE In PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE VRMA(3-2-88t Ll' ENSUS TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 02 OlJ Ld I YES NO ❑ . — (5 ERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT F 0 R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON LY. _ `\//\l ./'� DATA PROCESSMC COPY ��