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STATE OF CALIFORNIX WATER RESOURCES CONTRO BOARD FORM'A': UNDERGROUND STORAGE TANK PROGRAM SITEI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ( COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ?7r7 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) P'auTPx� <UVDARE SE '�f ✓ Box to indicate ❑ CORPORATION ❑ INDIVIDUAL Y��py A , /� K zlpcODE71 NEAREST CROSS STREET iMI TIO ❑ 'GMll N INDNIDDAI �o CITU NAME LOCATI N CODE CENSUS TRACT N y3. � C9<IfOP NSP ZIP COD ITg ZZ PIECINE If, WITH AREA CODE 2 - q ZI N ❑ 4 PROCESSOR ❑ 5 OTHER Y CLOSED SITE v FEE CODE " AT THIS SITE DD to O FACILITY/SIT NA <UVDARE OF DRESS INFORMATION ✓ Box to indicate ❑ CORPORATION ❑ INDIVIDUAL El PARTNERSHIP EISTATE-AGENCY ❑ LOCALAGENCY❑ FEDERAL -AGENCY ❑ COUNTY -AGENCY ADDRESS �/')D� r, Jl� , /� K zlpcODE71 NEAREST CROSS STREET iMI TIO ❑ 'GMll N INDNIDDAI ❑ PAWNEHRIIP ❑ AGENCY ❑ COUNT-AGENC! ❑ ffDEAALAGENCY AGEN ❑ GODNTI-AGENCY CITU NAME LOCATI N CODE CENSUS TRACT N y3. � STATE CA ZIP COD ITg ZZ PIECINE If, WITH AREA CODE 2 - q ZI TYPE OF BUSINESS ❑ p D TRISUTOR ❑ 1 GAS STATION 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER Box it INDIAN RESERVATION or TRUST LANDS ❑ EPA ID a FEE CODE " AT THIS SITE DD EMERGENCY CONTACT PERSON (PRIMARY) E RGENCY CONTACT PERSON (SECONDARY) DAYS: NAM (LAST, FIR T) PHONF\� W //H��AREA CODE DAYS\i AME (LAST, FIRST) PHH0 /gip WITH AREA CODE NIGHTS. NAME I FIRST) PHONE,p ITH AREA CODE /[i A NIGHT - NAME (LAST, FIRST) Q PRO p WITH AREA CODE q II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME f/ CARE OF ADDRESS INFORMATION MAILIN -S5ET gApRESS ` /l'� !!!/>` 6) ✓ Box to indicate ❑ CORPORATION ❑ INDIVIDUAL El PARTNERSHIP EISTATE-AGENCY ❑ LOCALAGENCY❑ FEDERAL -AGENCY ❑ COUNTY -AGENCY CITU NAM STATE zlpcODE71 CITY NAME PHONE N, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION MAILING o STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL -AGENCY V D BY NA j PHONE N WITH AREA CODE l ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, 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. 0 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION If 3�I AGENCY # a FACILITY ID # If of TANKS at SITE �O 10 101 10 41 CURB T LOCALAGENCY FACILITY ID N U_/k AP V D BY NA j PHONE N WITH AREA CODE l PERMIT NUMBER PERMIT APPROVAL DATE PWMITE PIRATI NDATE LOCATI N CODE CENSUS TRACT N y3. � SUPERVISOR -DISTRICT CODE w BUSINESS PUN FILED YES NO GATE FILED Aw- CHECI& PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B rIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATI NLY. FO M A (3-2- � ��y• v DATA PROCESSING COPY �/