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STATE OF C+ALIFORNIAL WATER RESOURCES CONTROL BOARD FORM 'A': `: UNDERGROUND STORAGE TANK PROGRAM Mo SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7-EERMANEWItY CLOSED SITE n ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE U I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME - CARE OF ADDRESS INFOHMATION a K ss Mo /Zf !32 ADDRESS NEAREST CROSS STREET ✓Bnb Nub D PAWIFISHP Cl STATEABDY YD CORPORATION D LOCAL-AGENCY D FEEFAL AGRO ❑ INDWOM D COUNTY AGDO CITY NAME .fr STATE ZIP Il QF/ / SITE PHONE N.WITH AREA � CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box N INDIAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRAUSTT LANDS SERVATION or ❑ AT THIS SITE 0 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(FAST FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS V 13 to im"le D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Inbicale D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE Y.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. ❑ II. ❑ 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY R FACILITY ID A N of TANKS U SITE [El 1 (0U 1114114 1 1010C) R:) CURRENT LOCAL ADENCY 1 CI TTY ID YAPPROVED BY NAME PHONE N WITH AREA CODE o10 o U5-� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS/TRACT Y SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE FILED —/�� 03 f/ 0✓ `L YES NO 6 CHECK IPERMIT AMO NT SURCHARGE AMOUNT FEE CODE RECEIPTY BY!t ,k THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) DATA PROCESSING COPY ��