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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM IAA: UNDERGROUND STORAGE TANK PROGRAM ;� �o SITE C�ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / s COMPLETE THIS FORM FOR EACH FA ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7PGpMANE}fTLY CLOSED SITE FV ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / �(,�(-/ V.I I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAM I J` T(:j- . o. �, ,tom' CARE OF ADDRESS INFORMATION all G(> f � r1r1/G/G ADDRESS / NEAREST CROSS STREET ✓BwwAoo, 0 PAW FWIP 0 STATE'AiXNCY 4 5 I T^ ❑ COWMT N ❑ LOcu ACENCY ❑ FEDE a A !Cr ❑ INmvlOuu ❑ CWNn.ACENCY CITY NAME STATE ZIP C,O0 SITE PHONE N,WITH AREA CODE / CA J > ` 76 _2 Cly-o79 TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ pROCES50fl ✓ ox it INDIAN EPA ID A ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS TIONal ❑ Not TANK's AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ) MAILING or STREET ADDRESS ✓Box lo,oax.le 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 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,od,cale 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,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: 1. ❑ 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 COUNTYLV JURISDICTION NAGENCY M FACILITY IDN N o/TANKS at SITE 3 ! = ! CURRENT LOCAL AGENCY FACILITY IDN J APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER fy—yi, PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS CTO SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 7 �j 1/ 1,/ YES ❑ NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNIESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. �,F i.. DATA PROCESSING COPY 1--i