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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM J' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 11 L COMPLETE THIS FORM FOR EACH FACILITY/SITE '�i•oaN" 11 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMAN SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURES I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILI SITE NAME 7 CARE OF ADDRESS INFORMATION ADORE, p' N EST CROSS STREET ✓BmbMc81 ❑ PNRTNERW 0 STATE AGDO O Z" G LJ 00 u o° o RnmN AGEBCv AGENC CITY NAME ^ STATE ZIP CODE SITE PHONE N,WITH AREA CODE V\ CA TYPE OF BUSINESS ❑2 DG BOOR ❑ pROCE550R ✓Box if INDIAN EPA ID N ❑ 1 GAS STATION FARA ❑ 5 OTTER TRUSTYLANDS ATION or ❑ AT THIS 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 Q NIGHTS: NAME(LAST,FIRST) P NEN WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADD SS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILNG or STREET ADDRESS ✓Box W Yxl Ie 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME S TE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE CO LETED) NAME CARE OF ADDR INFORMATION MAILING or STREET ADDRESS ✓Box to ildi [. 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: ❑ 11. ❑ 111. ❑ 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 COUNTYIIF JURISDICTION N AGENCY M FACILITY IDN If of TANKS N SITE E 106yf I / d5 doa CURRENT LOCAL AGENCY FACILITY ID N A"ROVED BY NAME n§ONE N WITH AREA CODE L D PERMIT NUMBER PERMIT APPROVAL DATE I PERM EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DA/TEE FILED a-3 a YES ❑ NO [:] /b _ l-) CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: - THIS FORM MUST BE ACCOMPANIED BY AT LEART H)OR MORE TANK PERMIT FORM'B'APPLICATION(SI,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.