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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM4 SITE // FACILITY/SITE, INFORMATION and/or , ERMIT APPLICATION ' L COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4s I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) aD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION tie�3� L l G ADDRESS //y/� NEAREST CROSS STREET ✓Barblydlf]L' O PAIUNERSHIP ❑ STATE AGENCY 11 CORPORATION ❑ LOCAL AGENCY ❑ FEDEF&-AGDtCY VVVV [�V ❑ INDFVOD ❑ COIATY.AGENCY CITY NAME STATE ZIP CODE SITE PHONE 1,WITH AREA CODE CA Y�� G TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑4 PROCEM011 ✓Box if INDIAN EPA ID 0 ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUSTYATION LANDS DF ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME ST,FIRST) // a PHONE 1 WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE It WITH AREA CODE Gb,.�T' L� 1� 2iJ 7`f— —03 NIGHTS. NAME(LAST.FIRST) PHONE 1 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 1 WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS J Box Fo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS JBox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCYCl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CIN NAME STATE ZIP CODE PHONE p,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: I. ❑ if. ❑ 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 d SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION B AGENCY B FACILITY ID K E of TANKS SI SITE = = I I I )1= © a CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE 1 WITH AREA CODE N /v PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ,) `. 3 1✓ YES NO 2 (/ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTY THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. / FORM A(3-2-81B) / DATA PROCESSING COPY i