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STATE OF CALIFORNIX WATER RESOURCES CONTR&BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM mo $� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m "(�_ COMPLETE THIS FORM FOR EACH FACILITY/SITE o,"`°"�� MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANEN SEO SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/ ITE NAM CARE OF ADDRESS INFORMATION e d rrt i��. NEAREST CROSS STREET ✓BWbMCYe Cl PWNMIP 0 STATEAGENCY ADDRE [ . I / /_m ry ^_ ❑ CUIPOAAiKKI ❑ LO[AL+VfM:/ ❑ FEDEfULAGENCY ��/-'F AW/ w/'v ❑ INomWu ❑ CWNI1'AGRICI CITY NAME (I CJI ' STATE ZIP CODE. CLO LSITE PHONE It,WITH AREA CODE CA o ' T O^( TYPE OF BUSINESS: EPA ID M ❑ 2 D TRIBUiOR ❑ /PROCESSOR ✓Box if TION o N of HIS SITE 5 OTHER RESERVATION or ❑ AT THIS SITE I GAS STATION 3 FARM ❑ TRUST LANDS 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 p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATIul ON r r'S • �• MAILING or STREET A DRESS ✓Box to Iftcare Cl PARTNERSHIP 0 STATE AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL O COUNTY-AGENCY ODE CITU NAME STATE LP CODE PHONE M,WITH AREA C but IW C/9 "O CaoR 33 - '01;1- 111. la- III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME -A / CARE OF gRESS INFORMATION (�('e pr e r' r I cit,- o-i�.v. �ie3tirwa� J � e P,N `c MA G or STREET A RESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY ' O ` /^ ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ai..� 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE c� a IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY R FACILITY ID K R of TANKS at SITE 6o a 01 1(:0 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE R WITH AREA CODE L PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCA"ONDE CENSUS TRACT N SUPERVISOR-DIBTIIICT CODE BUSINE88 PP S N F❑IIED NG ❑ DATE FILa PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M my: 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 ONL FORMA(3-2-BB)