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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ��` (q ; '".�.j •, o FORM 'A': ✓ UNDERGROUND STORAGE TANK PROGRAM � _ �e� z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ic COMPLETE THIS FORM FOR EACH FACILITY/SITE `'A�•oay`� MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANEN LY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE cn I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) ► FACILITY/SITE NAME CARE EEOFOF ADOR INFORMATION CAT T ADDRESS NEAREST CROSS STROIT G96PA]K Cl PAWN W Cl STATE AGDILY 3 ' ❑ oowmnoN ❑ IoCAL-AGBI Y 11Rmak AGENCY INXVD1 ❑ COUNTY.AGBILT CITY NAM ro STATE 7.Ip OODE� / SITE PHONE N.WITH AREA CODE l ` ajj�f CAS./^J{J TYPE OF BUSINESS: ❑ 2 DISTRISUT ❑ d PROCESSOR ✓Box d INDIAN EPA ID X E] I GAS STATION [—] 3 FARM 5 OTHER TRUSTY ATION LANDS GI ❑ N of TAKs SITE AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS AME(LAST,FIRST) 2, PHONE i WITH AREA CODE DAYS: rJAME(LAST,FIRST) PHONE u WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH TEA CODE NIGHTS' NAME(LAST,FIRST) PHONE A WITH AREA CODE a a _" UKN II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME p CARE OF ADDRESS INF MAT ON MAILING or STREET ADDRESS ✓ x to ie0icale ❑ PARTNERSHIP ❑ STATE-AGENCY ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CI NAME S ATEZIP CODE PHONE x,WITH AREA CODE N -111. TANK TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION W 4S MAILING or STREET ADDRESS ✓Box to,ftcale ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS 1 CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I III.❑ j THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. 1 APPLICANT'S NAME(PRINTED&SIGNATURE) DATE I LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N T FACILITY IDN N of TANKS N SITE OV 111 S 00 CURRENT LOCAL AGENCY FACILITY IDN AWROVEO BY NAME PHONE N WITH AREA CODE `LI 3 TVT PERMR NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISON-DISTRICT CODE BUSINESS PLAN FILED OA fll2 2 O YES NO S T CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ONLY. / \ FORM A(3-2-88) _ DATA PROCESSING COPY