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STATE OF CALIFORNN WATER RESOURCES CONTR61L BOARD �i '"""' ` i t (% �1 � FORM A: UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE �""�""�N MARK ONLY ❑ 1 NEW PERMIT F__]3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 2 ONE ITEM I^ 12 INTERIM PERMIT F-14 AMENDED PERMIT [:]6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE�yAME _ /JCJ CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION FACILITY ID K R of TANKS at SITE 1 1 1410113v ADDRESS ✓BOXI irrdcate ❑ PARTNERSHIP ❑ STATE -AGENCY NEAREST CROSB STREET o ❑ PAANEI9IF ❑ SfAli'AGENI CY PO❑ LOgAGDY ❑ FEDERAL-AGEN ��CMA CITY NAME / Y ZIP COOS6,3c—XQ PHONE p, WITH AREA CODE ❑ DAINTY-AGENU CITY NAME �jI CENSUS TRACT N a 3, ;,3 STATE ZIP CODE SITE PHONE N. WITH AREA CODE PERMIT AMOUNT CA FEE CODE TYPE OF BUSINESS: ❑ @ DI IBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID N X of TANK'a -11 GAS STATION FARM ❑ 50THEq RESERVATIONor ❑ 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 ARFA CODE NIGHTS'. NAME (LAST, FIRST) PHONE N WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION 81 ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION P U FACILITY ID K R of TANKS at SITE 1 1 1410113v MAILING or STREET ADD SS ✓BOXI irrdcate ❑ PARTNERSHIP ❑ STATE -AGENCY APPROVED BY NAME PHONE N WITH AREA CODE ❑ fJ,IRPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE_ ZIP COOS6,3c—XQ PHONE p, WITH AREA CODE , CENSUS TRACT N a 3, ;,3 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION E FACILITY ID K R of TANKS at SITE 1 1 1410113v MAILING or STREET ADDRESS ✓ Box to intllcate ❑ PARTNERSHIP ❑ STATE -AGENCY APPROVED BY NAME PHONE N WITH AREA CODE ❑ CORPORATION C LOCALAGENCY❑ FEDERAL -AGENCY Cl 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: I. ❑ if. 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. J APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY X = JURISDICTION R = AGENCY B = FACILITY ID K R of TANKS at SITE 1 1 1410113v CURRENTFL AL AGEN FA{,LLITy q N EQ/(]�1 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ODE LCHECK# CENSUS TRACT N a 3, ;,3 SUPERVISOR -DISTRICT CODE ✓� BUSINESS PLAN FILED YES NO ❑ DA E FI D PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: �eLl 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) lausi DATA PROCESSING COPY 0 N IV O