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STATE OF CALIFORNIX WATER RESOURCESCONTROZiBOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM = SI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION lz�KPERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bulo,,doeM ❑ PAUNFIS1IP ❑ STATE AGENp ❑ CORPORATION ❑ UXA4AGM ❑ RRA AGENI.Y ❑ INDIVIDUAL ❑ COI1M AGENCY CITY NAME STATE ZIP CODE SI E PHONE p,WITH AREA CODE O G id, U CA a ao 3 0 TYPE OF BUSINESS+ ❑2 DIS OR ❑ 1 PROCESSOR ✓Boz if INDIAN EPA ID N RESERVATION or /� N of TANMF ❑ 1 GAS STATION ARM ❑ S OTHER TRUST LANDS ❑ / /tr � AT TNIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE i r o iie Cao 3i- 1� NIGHTS. N S ST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE s -yyo - IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME ^ CARE OF ADDRESS INFORMATION l.Dr_ MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTN 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 R AGENCY R FACILITY ID N N of TANKS at SITE F3-m [= = 10161214=z600 CURRENT LOCAL DENCY FACILITY 10If APPROVED BY NAME - PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE OCATIDNGODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA FI D 3 � YES NO A s ^ IC HECK EE PERMIT AMOUNT SURCHARGE MO NT FEE CODE RECEIPT N BY: r THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONNNNNNN� FORMA(3-2-88)