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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM IA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION . o c— COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ER<CIANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"A' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O Q —4 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION I ADDRESS II c NEAREST CROSS STREET ✓BmwI oow, ❑ PA%MPBBHIP ❑ STATE RGENCV U/ 1 P�Li NI(�h/1 ❑ I111MALION El COUNTY,1G� ❑ FD)EERIL FGENCI' CY CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE CA 52AS� - Z TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box i1 INDIAN EPA ID p RESERVATION or F of TANK'S ❑ 7 GAS STATION ❑ 3 FARM ❑ 5OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE•WITH AREA CODE 3-6z1 NIGHTS: NAME(LAST,FIRS PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME // r , CARE OF ADDRESS INFORMATION MAILING or STR E DRESS ♦ _ ✓B ointlicale ❑ PARTNERSHIP ❑ STATE-AGENCY 3 //y� ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY (//G INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE N.WITH AREA CODE a-i9- spa'DE P. Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/B..lo,ndicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE ft,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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY R FACILITY ID M K of TANKS at SITE 12-1 3=I 1 CURRENT LOCAL AqENCY FACILITY ID N APPROVED BY N ME PHONE•WITH AREA CODE 2 �{� 8 e-( PERMIT NUMBER PERMIT APPROVAL DATE FIE IT EXPIRATIO ATE LOCATION CODE CENSUS TRACT•/, SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Z3-Uv s7 YES NO � CHEC • PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: 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 -.!