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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 4 1 VSIm� i FORM A : UNDERGROUND STORAGE TANK PROGRAM �o SITE A FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION /T COMPLETE THIS FORM FOR EACH �. a ict. MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT CHANGE OF IN 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CL URE i0 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAMECARE OF ADDRESS INFORMATION ADDRESS ' / NEAREST CROSS STREET ✓Bodo�lgicale ❑ PARitI P ❑ Si0.TE-ABFNLY (p ❑ fAP,niatte AGFNCY ❑ FEDER&AGDSTATEA END'Y N ❑ INDIVIDUAL ❑ WUNIV-AGENCY CITY NAME STATE ZIP CODE SITE PHONE J!,WITH AREA CODE CA 4SR TYPE OF BUSINESS: EPA ID a ❑ 2 DISTR OR ❑4 Pfl0 R ✓Box if TION o N of TANK'I / ❑ 1 GAS STATION ❑3 FARM OTHER TRUSTRESERYLANOS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) Sp�arPHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS:- NAME( ,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAM ST.FIRST) PHONE#WITH AR/TEA/CODE rn/ b 31-� II. PROPERT OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or SiAEET AD SS 3 baa ✓Box to indicate ❑ P RSHIP ❑ STATE-AGENCY ❑ CORPORATION OCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE At.WITH AREA CODE Ill. TANK OWNER INFORM ION & ADDRESS - (MUST BE COMPLETED) NAME `� CAREAF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz to indicate [J PARTNERSHIP El STATE-AGENCY ❑ CORPORATION 11 LOCAL-AGENCY ❑ 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. ❑ if. Epelli.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY /J COUNTY N 'JURISDICTION R AGENCY# F ILITY ID R '/ #of TANKS at SITE 39 � � 0 X 13 13 [01 00 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY E PHONE#WITH AREA CODE 73 PERMIT NUMBER LPERMITPPROVAL DATE PERMIT EXPIRATION DATELOCATION CODE CENSUS TRASUPERVISOR-DISTRICT CO E BUSINESS PLAN FILED DATE FILED3YES NO CHECK/ PERMIT AMOSURCHARGE AMOUNT FEE CODE RECEIPT N BY: \ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(r4R MORE TANK PERMIT FORM IS'APPLICATION(S), UNLESSTHIS ISACHANGE OF SITE INFORMATION ONLY. ` \ FORM A(3-2-88I DATA PROCESSING COPY