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STATE OF CALIFORNIAWATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / z COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1015 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE— ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ;di r I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) 40 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS I NEAREST CROSS STREET ✓111 0 PARTNERSHIP ❑ STATE AGENCY 10� ❑ WRPORATION 0 LOCAL AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 OOUNIY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA a CA - y TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID # ESE❑ 1 GAS STATION [:]3 FARM ❑ 5 OTHER TRUSTYLANDS ATION ar ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE aoq v&3-9wo NIGHTS: NA LAST, RST) - PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II 11 11 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NA CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY 13 1 %1 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Dr. 0 INDIVIDUAL 000UNTY-AGENCY CITY NAME STATE PZIPCOOE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box 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#.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. 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE FTTI CURRENT LOCAL Y FACI TY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT PIUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA©N CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED E±j YES NOCXECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# J THIS FORM MUST BE ACCOMPANIED BY AT LEAST f1�MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. `— FORM A(3-2-88) I v Tl DATA PROCESSING COPY v 1 I >�,LQ— �i