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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD yT S FORM 'A': ate ; UNDERGROUND STORAGE TANK PROGRAM ' �o SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE FMARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN TLY LO D SITE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) -4 FACITY/SI NAME CARE OF 4C)PRESS INFORMATION ADDRESS 41 3 I [j ^ ' NEAREST CROSS STREET ✓BoxloiMicale ❑ PAATNERSHIP ❑ STJGODE `•t// /4�-J�� L ❑ CORPORATION ❑ LOCALAGENCY ❑ INDIVIDUAL ❑ CDUNMAGENCY CITU NAME STATE ZIP ODE SITE PHO E WITH AREA CO D l CA TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID 4IASTATION 3FAflM SOTHER RESERVATION orAT THIS SITE❑ ❑ TRUST LANDSEMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) IRSTI- PHONE N WITH AREA CODE YSN E(LAST,FIRST) P NE p WITH AR� T4 - aNIGHTS. NAME( S ,FIRST) PHONE 4 WITH AREA CODE NIGHTQS'JAAME(LAST,FIRST) NE p WITH AR ✓1 " II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME I CARE OF ADDRESS INFORMATION ahrt MAILI G or STREET ADDRESS ✓Box to in0icale 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MA ING or STREET ADDRESS ✓Box to in4icaM ❑ PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,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 If AGENCY K FACILITY ID N M of TANKS at SITE mil O © 4 161 1 ,00 loll C RRENT LOCAL AGENCY FACILITY ID 0 APP OVED BY NAM PHONE N WITH AREA CODE E� A 3 Z PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXIIIIIIATION DATE LOC ONCODE CENSUSTRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ATE FILED QQ Z ,g� YES NO �6 Z II 1 CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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. FORM A(3-2-88) . DATA PROCESSING COPY