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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o P : COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PER CLOSED SITE cm ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Q" I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACIUTY/SITENAME - CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓S wwaN 0 PM UIP 0 STATEAGM '7f 3__r6q ES RD 00 V�OMDUALIDR O (........... ❑ +(AGEwc CITY NAME STATE ZIP CODE SITE PHONE �IT-H AREA COD� CA 4S7 79-g3 6 8 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4ESSOR ✓Boz d INDIAN EPA ID a a of TANK s ❑ 1 GASS'FATION ❑ 3 FARM OTHER TRUST LANDS RESERVATION of ❑ ATTHISSITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE teto _ g3g 668d' NIGHTS: NAME LAST.FIRST PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY MAILING or STREET ADDRESS 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE 21P CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If,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. ❑ It. ❑ 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) GATE LOCAL AGENCY USE ONLY COUNTY a JURISDICTION If AGENCY N FACILITY ID R a of TANKS at SITE l b dG ° / CURRENT LOCAL AGE CY FACILITY ID a APPROVED BY NAME PHONE a WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIIONLC'ODE CENSUSTRACTryN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE U D Z YES [j NO J CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY. I THIS FORM MUST BE ACCOMPANIED BY AT LP°'(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S1 UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-288) ...- DATA PROCESSING COPY „r'