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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD e FORM `A1: UNDERGROUND STORAGE TANK PROGRAM SITEACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F LITY/SITE `'��•e `" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 NTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION� �,�Yice �/M ADDRESS NEAREST /C/,ROSSSS STREET ✓ftm oxao 0 PARTNUGHIP 0 STATER imY 4/" _/ /x � x I'J 0 I DWMTION 0 LOCILAGENCY 0 FEDERAL- AGENCY 0 INCNIDUN 0 CIXMfYAGENCY CITY NAME STATE ZIP CODE // SITE PHONE a.WITH AREA CODE / CA -76 TYPE Of BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box' INDIAN EPA ID a ❑ 7 GAS STATION 3 FARM 5 OTHER RESERVATION or F of TANKY ❑ ❑ TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE I.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 0 STATE-AGENCY Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVB ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ 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 M AGENCY R FACILITY ID M A of TANKS at SITE M = yo CURRENT LOCAL AGENCY FACILI a APPROVED BY NAME PHONE R WITH AREA CODE 1f PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 03 9 YES [:] NO E3 1 /U— S CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'Br APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FORM A(3-2-88)