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STATE OF CALIFORNOr WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE' INFORMATION and/or PERMIT APPLICATION y.. COMPLETE THIS FORM FOR EACH FACILITY/SITE '�-- MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT k1l CHANGE OF INFORMATION ❑ 7 PE A TLY LOSED SITE PV ONE ITEM ❑ @INTERIM PERMIT ❑ 4 AMENDED PERMIT Ll6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACI TY/SITE NAM r rN(�I OARS F ADDRESS INFORMATION r A ADDRESS NEAREST CROSS STREE ✓�Wointlrale 0 PARTNERSHIP 0 STATE AGENCY / A L _ 9'CAR DUAEl LOCAL AGENCY El LION 1-1TYAGENCY FEDERAL AGENCY J CITY NAME SSTAVTEC+�S� ZIP CODESITE PHONE ,WITH AREA CODE Lo �� CA Z Zo`i TYPE OF BUSINES 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA IO a If of TANK'x ❑ 1 GASSTATION ❑ 3 FARM OTHER TTRUSTYATION LANDSo [::i ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) D S'. NAME T,FIR T) HONE p WITH AREA CODE DAYS N ME(LAST,FIRST) PHO WITH AREA CODE � NIGHTS. NAME(LAST,FIRST) HONE#WITH AREA CODE NIGHT - AME(LAST.FIRST) PH NE WITH AR EA CODE ,q A J d IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILINCI or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCALAGENCY0 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) NAM I"� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY ❑ INDIVIDUAL 0 COUNTYAGENCY 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. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION a AGENCY# FACILITY ID# #of TANKS at SITE ® = = 4 6 6 3 p l3 CURRENT LOCAL AGENCY FACILITY IDM APP OVED BV NA PHONE#WITH AREA CODE r4f-Vr PERMIT NUMBER PERMIT APPROVAL DATE P RMIT EXPIRATION DATE LOC740DE CENSUSTRACTM SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED 2 �a 3�o YES ❑ N !� CHEC M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY U.II