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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �^ FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SITE I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,; COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT m 5 CHANGE OF INFORMATION ❑ 7_21161VIANiNTLY CLOSED SITE I"� ONE ITEM ❑3 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 4 E)0 FACILITY/SITE NAME �� CARE OF ADDRESS INFORMATION A g ADDRESSL4 ,16— NEAREST CROSS STREET bini ❑ PARfNEBSHIP ❑ STATE-AGENCY WR'ONATION ❑ LOCAL-AGENCY ❑ FEDIXAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP ODE SITE Pyyoy p.WITH AREA CODE CA S' 76 V- TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4PROCESSOfl Box if INDIAN EPA ID k of TANK's 5 RESE E] 1 GAS STATION ❑ 3 FARM E] OTHER TRUSTYLANDS or El IAT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(717) PHONE 4 WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE U VIc V AL NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE I WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME ^ - CARE OF ADDRESS INFORMATION 1 \J" MAILING or STREET ADDRESSxto indicate E] PARTNERSHIP STATE AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME / W W CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS /Wax to indicate El PARTNERSHIP ClSTATE-AGENCY ORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ 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. IL ❑ 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 R AGENCY k FACILITY IDM M of TANKS BL SITE M] = / ? 4f/ O CURRENT LOCAL AG CY F;LITy ID 7 APPROVED BY NAME PHONE It WITH AREA CODE LPERMITNUMBER U /4\ ,_([ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUSTRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: jZS 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) DATA PROCESSING COPY