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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A : UNDERGROUND STORAGE TANK PROGRAM SITE (�f FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o u COMPLETE THIS FORM FOR EACH FACILITY/SITE FARK,ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �7 PERMANENTLY CLOSED SITE IrNE TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Tce- N� AOORE55 NEAREST CROSS STREET ✓Bwir,adok ❑ P/ABBTNIP ❑ STATE-AGNIV `3S S A (/Q( cccQ�o ❑ CGRP TION ❑ Locu.AGBucr ❑ AMOW.AGErx.Y ❑ INoi ❑ WIRCY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE NAME CA 2--0!% u K N TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESWfl -/Box if VA INDIAN EPA ID x ❑ ❑ TRVA USESET LATION NDS or ❑ AT THIS SITE I I GAS STATION 3 FAflM 5 OTHER EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,(LAST,FIRST) PHONE 0 WITH AREA CODE 1 ,J _w/ — 32- i NIGHTS.�NAME//LAST,FIRST) PHONE N WITH AREA CODE NIGHTS N ME(LAST,FIRST) PHONE M WITH AREA CODE c/6erj luau' , - 52-1/9/ u1�'n0 11. PROPERTY OWNER INFOR ATION & ADDRESS - (MUST BE COMPLETED) NAME d qA) CARS/�fv OF ADDRESS INFORMATION MAILING or STREET ADDRES / ✓BBo to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION .@ROCAL-AGENCY Cl FEDERAL-AGENCY D rwlk ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME 1 STATE ZI� E �O^ �pWI�/REA CODE �— III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMEer CARE OF ADDRESS INFORMATION one s MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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. ❑ 11. vIII.❑ 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 R JURISDICTION N AGENCY M FACILITY ID S M of TANKS at SITE 0ooa ob 0 HL CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WRH AREA CODE rm K PERMIT NUMBER PERMIT APPROVAL D TE PERMIT EXPIRATION DATE LOCATION CODE CENSUS ,CT 0 SUPE 1$�- IST111CT CODE BUSINESS SN FILED NO ❑ D �1LE� C CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X BC 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 ONLY FORM A(3-2-88) Ni DATA PROCESSING COPY