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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM S!T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FOR EACH F ILITY/SITE �'"•tee"�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEN Y CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/S`TE CARE OF ADDRESS INFORMATION ADDRESS N�( NEAREST CROSS STREET_ ✓BmbM ❑ PMMR9W ❑ STAIEAGENLY O '� 47' ❑ CJWMTON O L IGf.N(,r ❑ FEDEW AGEHLv N ❑ INDIVIDUAL r-ncENa CITY NAME / / STATE ZI ODE SITE PHON N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BoX if INDIAN EPA ID N RESERVATION ar � ��L� Mol TANK'L ❑ 1 GAS STATION ❑ 3 FARM �IOFHEP TRUST LANDS ❑ /✓" " AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME C- FIRSTI PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE a HTSNAME(LAST,FIRST) I PF16NE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADD SS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS— (MUST B COMPLETED) NAME CAR OF ADDRESS INFORMATION MAILING or STREET ADDRESS B. a nd,cate D PARTNERSHIP ❑ STATE-AGENCY ❑ COR RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVI L ❑ COUNTY-AGENCY 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 A BILLING: I. ❑ U. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN LEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DA E LOCAL AGENCY USE ONLY COUNTY B JURISDICTION N AGENCY B FACILITY ID R If of TANKS at SITE m 1010 3 161 al D CURRENT LOCAL AGENCY FACILITY to ID N APPROVED BY NAME PHONE•WITH AREA CODE /V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D E a YES NO CNE • PERMIT AMOUNT SURCHARGE AYOUNT FEE CODE RECEIPT N THISFORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. ��J FORM A(3-2-98)