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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILI7Y/SITE MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN LOSED SITE N ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &/(AgD/DRREESS - (MUST BE COMPLETED) FACILITY/SITE NAME / _ / !' "'- CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bwb Mime 0 PAATNEHSHIP 0 STATE AGENCY / 3 0 CONPOHATION 0 LOCAL AGENCY 0 FELFRAL AGENCY ❑ INDIVIDUAL ❑ COUNTAGENCY CITY NAME V STATE ZIP CODE SITE PHONE A.WITH AREA CODE 1 �M TYPE OF BUSINESS: CA ❑ 2 DI IBUTOR F-] 4 SSOR ✓Box it INDIAN EPA ID x RESE❑ I GASSTATIDN ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION dr ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(AST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boa I.iftcale 0 PARTNERSHIP 0 STATE-AGENCY El CORPORATION 0 LOCAL-AGENCY 11 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ ul_E77 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 X JURISDICTION X AGENCY M FACILITY ID A B of TANKS BI SITE ` CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE t WITH AREA CODE L/7, !!�ORlr �, PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT F SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO 2 CHECK I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 4 BY:/ THIS FORM J MUST CCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-68)L� -/ J DATA PROCESSING COPY Y /