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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD `" '` u FORM 'A': UNDERGROUND STORAGE TANK PROGRAM 1 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION zCOMPLETE THIS FORM FOR EACH FACILITY/SITE `"A�Po•"`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 1vr7 PERMANENTLY CLOSED SITE F"a ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE W I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATI r fit YY�� ADDRESS NEAREST CROSS STREET ✓Ba m iEub 0 PAIIINER3NIP STATE-AGENCY eI �v` ❑ CGRPo0.ADON ❑ LOCAL AGENCY ❑ FBIBSLAGENCY S F_ I a INDWIWk Cl ODU04IGENCY CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE C)Vr CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4PROCESSOR Box if INDIAN EPA IDN RESERVATION or N of TANICS e) ❑ i GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME q _ CARE OF ADDRESS INFORMI,ATJpN ,L',(_�J'(l f w� (L(J� MAILING or STREET ADDRESS ✓Box to irdicale C PARTNERSHIP STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY C FEDERAL-AGENCY ❑ INDIVIDUAL C COUNTY-AGENCY CIN NAME STAtiE ZIP CODE � 9 9(--RPHONE N,WITH AREA E �� III. TANK OWNER INFORMATION & ADDRESS — (MUST BE L/COOM—PLETE/�Dy')rJ�`j^, NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate 0 PARTNERSHIP C STATE-AGENCY 0 CORPORATION C LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE 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 N JURISDICTION If AGENCY R FACILITY ID a X of TANKS at SITE = = I D 3l I CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE N WITH AREA CODE n rl I -a,-) PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONCODDE CENSUSTnRRACT CM�/\ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED t d blJ 19 YES NO ❑ 1—ID-VI 0"--) CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT \ 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 ��