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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD rt,Pt r T FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE ` FORK P 9 e MARK ONLY 521 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOSER SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N FACILITY/SITE NAME f, CARE OF ADDRESS INFORMATION Y S-Ow's ADDRESS NEA ST CROSS STR ET ✓8or to indicateTNER5HIP ❑ STATE AGENCY /} 1-1CORPORATION ❑ LOCAL-AGENCY LlFEDERAL-AGENCY +L! D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZI CODE I SITE PHONE#,WITH AREA CODE r CA c� oZQ ��1p3 TYRE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P OCESSOR ✓Box if INDIAN EPA 1D # #of TANK's ❑ 1 GAS STATION E] 3 FARM OTHER TRUST�LANDS ATION or F-1ATTHIS SITE A EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,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 INFORMATIO & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY _ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - UST 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 TATE I ZIP COOS PHONE 0,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LE L NOTIFICATION AND BILLING: 1. ❑ If. ❑ HI. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TH EST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY [ COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANK$at SITE [m] I I 1 :1 El I I L0 / �,` CURRENT LOCAL AGENCY F GILITY ID q APPRqVR BYNAME PHONE#WITH AREA CODE a [PERMIT NUMBER PERMIT APPROVAL DA Q�� PERMIT EXPIR TION DATE CATION CODE CE S TA.AG SU ERYI OR-DISTRICT CODE BUSIN S P N FILED DATE FILED (3 �;{f � YES [—] NO ❑ / CHECK# PERMIT AMOUNT SURCHARGE AMOUNT _7_FEE CODE RECEIPT# BY: 17 THIS FORM MUST BE ACCOMPANIED BY AT LEASTORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESq THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) (1M CD--�_ .0\ DATA PROCESSING COPY