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STATE OF CALIFORNIic WATER RESOURCES CONTRdCBOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G r 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Eti ADDRESS NEAREST CROSS STREET ✓SmbndaM ❑ PWTNBEHIP ❑ STATE AGFNY f163 S OU/�AAv1I ° �°N ° `OAD ❑ " AGEc o I o DOM CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 0 CA ?S33o TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N RESERVATION or F of TANK'* ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAMEJoh* CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓B to iedicale 11 PARTNERSHIP ❑ STATE-AGENCY ��,.,� C ORPORATION El D FEDERAL-AGENCY J INDIVIDUAL Cl COUNTY-AGENCY CITY NAME r"' STATE ZIP CO_DE PHONE N,WITH AREA CODE (( -36 1 Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -./Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ 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. ❑ it. ❑ 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 M JURISDICTION F AGENCY R FACILITY ID R R of TANKS N SITE " '�—.r� = O 1 It' CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE*WITH AREA CODE Ad,eNnc t'7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATON CODE CENSUS TRACT N SUPERVISOR-DISTRACT CODE BUSINESS RAN FILED DATE FI D 2 3 •23 5 Z t0 I YES ❑ NO ❑ 2(J CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* 'C-7 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)00 MORE TANK PERMIT FOR M 'B'AFPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \FORM A(3-2-88)