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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 GCOMPLETE THIS FORM FOR EACH FACILITY/SITE o " MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 53 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION C45�A, 2 +'jf .Y5 ,I ADDRESS NEAREST CROSS STRE ✓BatItto le 0 PARINMIF 0 SrATEAGENDY 0306 S. 1oIJeF �� ❑ DO"MTON 0 LoinAGEND 0 FMk-AGDO ❑ ININDUAL 0 0DJN7Y AGEND CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE k CruCA TYPE OF BUSINESS. q DI-1 STRIRI ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N ❑ i GAS STATION ❑ 3 FARM ❑ 5 OTHER RESETRUSTVATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to i,d,cate 0 PARTNERSHIP 0 STATE AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Ron to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R rr AGENC�Y k FACILITY IDR R o/TANKS SI SITE CURRENT LOCAL AGENCY FACILITY ID R APPROVED BY NAME PHONE N WITH AREA CODE 6A510 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCONCE ATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED I? 23'so 3 x s YES [:] NO 6� 8 110 CK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: I� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. u' / FORMA(3-2-Se)