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_.. ., ..; WINrwt STATE OF CALIFORNIP WATER RESOURCES CONTROBOARD �F 5^` 1. FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE Ea FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-11 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Efr7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE A 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 'J Co FACILITY/ TE NA � . CARE OF AD EBS INFORMATION A ADDRESS NE REST CROSS STR ET ✓Bwbi state ❑ PyrtNBISAP ❑ STATE AGEYLY + ,yV �• to Mum 11001POunoN Q�COIL AGEND 11FEDERAL AGI ❑ INDIVIDUAL ❑ WUNIY-AGENCV CITY NAME STATZ 0� i�V0I ( kWITH AREA CODE CA TYPEOFBUSINESS: ❑ 2DISTRIBUTOR ❑ PROCESSOR ✓Box if INDIAN EPA ID k 3 3 RESE ❑ ❑ TRUST LANDS Gr ❑ G6.�O/? 3 3 ! #of TANK'# O� 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY NAME(LAST,FIRSk I PItIONE It WITHAREA CODE DAYS'. NAME(LAST,FIRST) P ONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) H NE k WITH AREA CODE NIG ' AME(LAST.FIRST) xx P E k WITH AREA CODE 5,14 11. PROPERTY OWNER INFORMATION St ADDRESS— (MUST BE COMPLETED) dY, NAME C)JF DDRES INFOR�TIQN �L MAILING or STRE QD R SS �(/^/ e7 A ✓Box lPORA IO ❑l/rOCAL-ADEN ❑ STATE-AGENCY 2 �l/ ('/•� � ❑ CORPORATION El COUNTY-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME / STAT_E ZIP ODE- - - H NE k,W TH AREA CODE 04 III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMP ETED) NAME CARE OF ADDRESS INFORMATION MAILING or ST EET ADDRESS ✓Box to indicate Cl PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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. ❑ it. Rf 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 CmNTY N JURISDICTION# AGENCY# FACILITY ID k #o/TANKS at SITE UI / I 010 38 � D b I DD CURRENT LOCAL AGENCY FACILITY ID N APP V DBY NAM / PHONE N WITH AREA CODE G/ 'T 006 PERMIT NUMBER PERMIT APPROVAL DATE PER IT E%PIR TION D TE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO `'DLL1[Tti 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(3-2-88) 0 DATA PROCESSING COPY 0