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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 COMPLETE THIS FORM FOR EACH F ILITY/SITE R MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ED SITE N a. ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CY) W. I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) a► FACILITY SITE NAME CARE OF ADDRESS INFORMATION ADDRE3 /1 G ��-y- NEAREST ROSS STREET ✓ftloir�acek 13PAKNEWIP ❑ STATE-AGENLY BD ❑ CGAPCMIION ElLOCALAGENC/ El RDEIUL-AGENCY JJ�f II o ❑ INONIDUAL ❑ WUNN AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA OJr TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓BOY if INDIAN EPA ID p ❑ 1 GAS STATION ❑3 FARM OTHER RESERV A I OATON Or ❑ M of HIS SITE AT THIS TFE EMERGENCY CONTACT PERSON(PRIM ) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(UST,FIRST) PH NE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION & AD RESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (11116,PT BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓BOX to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME ATE 1 ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH EGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND T THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIN JURISDICTION If AGENCY# FACILITY ID# R of TANKS at SITE � -010 1 CURRENT OCAL AGENCY FACI I a APPROVED BY NAME PHONE#WITH AREA CODE PERMIT N MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT(j/,/�� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED a3 . Q V YES [:] NO L ( " CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM (l 1� THIS FORM MUST BE ACCOMPANIED BY AT LEI 7T(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S) "NLESS THIS IS A CHANGE OF SITE INFORMATION OILY. �\♦ FORMA(3-2-68) \V\ � DATA PROCESSING COPY '�*'