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.yEp W0,��'>tiF STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD \ FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or ERMIT APPLICATION _fOPN'P COMPLETE THIS FORM FOR EAC AGILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER TLV CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 Ul r I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) m FACILITY/SITE NAME rh H C CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BOtlOxdezle ❑ LOCALPASTSAGENCY ❑ STATE FEDERAGENCY r L�r )L� ❑ COWIDUAL0N ❑ COUNTY ❑ FEDEMLAGENLY ❑ INDIVIDUAL ❑ CAUNttAGEN61' CITU NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE ! CA TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 P ESSOR ✓Bax it INDI N EPA ID p M of TANK's RESERVATION or El THIS SITE (./ ❑ I GAS STATION F-1 OTHER 3 FARM TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIR j PHONE 0 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION (Q C/ MAILING or STR ETADDRESS pe- ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ^ O CORPORATION ❑ LOCAPAGENCY ❑ FEDERAL AGENCY 1� ❑ INDIVIDUAL Cl COUNTY-AGENCY LA CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE S �5 � 6-A- 1gsiZ- 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Set,ltia a s Z MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. L� III. LJ 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 K AGENCY N FACILITY ID R If of TANKS at SITE 3 � OGS VD_?m 10101611 CURRENT LOCAL AGENCY FACILITY ID# L PHONE M WITH AREA CODE 5 % F 27] PERMIT NUMBER PERMIT APPROVAL DATEXPIRATION DATE LOCATION CODE CENSUS TRACT k SUPERVISOR- S PLAN FILED DATE FILED p Z t YES [j NO �CHECK# PERMIT AMOUNT SURCHARGE ARECEIPT If 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI FSS THIS IS A CHANGE OF SITE INFORMATION ONLY Al FORM A(32-ee) ow DATA PROCESSING COPY �- \ -liv