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NATE OF CALIFORNI100" WATER RESOURCES CONTROkOARD '`� 'e FORM 'A': V UNDERGROUND STORAGE TANK PROGRAM �" SITE �, /FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F LITY/SITE °4��.oa��^ I MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE CLOSEDSITE I-& ONE ITEM ❑p INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —I 1.FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) (7) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W G KG �Z14 ADDRESS '� NEAREST CROSS STREET ✓BOx Ibi ❑ PANINDWIP ❑ STATE-ASBC �h� ❑ cORP DIN ❑ LOrx,LTBILY ❑ R�Exu-ArB+cY ❑ INDIVIDUAL ❑ LUUIBY-Amcy CITY NAME � A STATIN ZIP COD �� SITE PHO =.WRH AREA CO TYPE'pF BUSINESS: ❑p DISTRIBUTOR ❑/PROCESSOR I f Bat if INDIAN EPA ID# 6 1 GAS STATION ❑3 FARM ❑5 OTHER TRUSTYLANDS Or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) , PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE // NIGHTS: NA FIRST) I PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING Or STREETAODRESS */Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY &j� /,#�/�, /� ❑ CORPORATION 13LOCAL-AGENCY ❑ FEDERAL-AGENCY r /" J /Nv ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE�� III. TANK OWNER INFORMATION & ADDRESS — ( UST BE COMPLETED) S NAME -� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bot to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. E 11. OIL❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGF-IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY# FACILITY ID If If of TANKS at SITE v1 z3 o CURRENT LOCAL AGENCY FACILITY ID# A.f' APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO C DE CENSUS TRACT Mu,'I SUPERVISOR-DISTRI CODE BUSINESS PLAN FILED DATE FILED ql 2 V v 2 YES [:] NO CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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. FORM3-2-SSI DATA PROCESSING COPY 1