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01 STATE OF CALIFORNnq WATER RESOURCES CONTRA BOARD v FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =" SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 'L COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Z PERMANENTLY CLOSED ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST_3-3 ^ / / / NEAREST CROSS STREET ✓BwtlWT NRNMa ClSTATE#GANG( 114J� �- (Vfi(1//•1/ O Ir DJAI 0 t 11EEGExu acENcr CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA5- 35- IQ TYPE OF BUSINESS: ❑ 2 01 IBUTOfl 4 PROCESSOR ✓Bax it INDIAN EPA ID # N of TANK'4 TRUSRESETYATION LANDS or ❑ //I d _ O ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER �' Ll(/ !�"�� 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 N NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S MAILING or STRE&ADDRESS ✓Box to tnoiwte Cl PARTNERSHIP 0 STATE-AGENCY S �t ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMEQ t CARE OF ADDRESS INFORMATION J MAILING or STREET ADDRESS ✓Box taintlicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ASOVB ADDMSS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 E JURISDICTION k AGENCY B FACILITY ID E R of TANKS SI SITE m = 101C)IL/ lTlEfl 1010101 CURRE OCAL AGENCY FACILITY 4 APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CE BUS TRA # SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED a1 YES NO /a CNE # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. FORMA(3-2-88)