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STATE OF CALIFORN10 WATER RESOURCES CONTROBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM V � SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , S CO 74 COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I" ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /n� —4 Y/ 00 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION / ADDRESS NEAREST CROSS STREET ✓Box to vdiak ❑ FARTNEFEw El STATE AGENCY aD O ❑ CORPORATION 11LWALAGENCY ElFEDERALAGENCY ONDUAL ElCOUNTY-AGENCYCITY NAME STATEZJ,�CODE SITE PHONE#,WITH AREA CODE Le btoi CA 367 TYPE OF BUSINESS: ❑p DISTRIBUTOR F-14 PROCESSOR `/Bax it INDIAN EPA ID # ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUSRESEr IF of TANK's TVATION LANDS 0 ❑ AT THIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(I-AST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST( PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OFADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.ti,aidcate Cl PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (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#,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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE [K�l = = 1 1 141611131 CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATI N CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILE 3 YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-z-BB) r r # DATA PROCESSING COPY