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STATE OF CALIFORNrs-i WATER RESOURCES CONTH,AL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION go COMPLETE THIS FORM FOR EACH FACILITY/SITE °'�,xoew`• MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE17 77 F � I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) v !V FACILITY/SITE NAME / /J / CARE OF ADDRESS INFORMATION ADDRESSNEAREST CROSS STREET ✓ftAo W D PARTMNBIP D STATE AGENCY D COW MTDN D LOCAL ABDO D FEDER4-AGENCY D IMAM D courrv-AGBICI CITY NAME WN STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTR18UTOR ❑ d PROCESSOR ✓Box i1 INDIAN EPA ID N ❑ If of TANK' 1 GAS STATION [:] 7 FARM ❑ 5 OTHER TR STYLANDS ATION or ❑ AT THIS SITE 0 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to iMicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENGY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING Or STREET ADDRESS ✓13.10 mclicate D 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)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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION E AGENCY M FACILITY ID N N o/TANKS BI SITE ® E= 1 ,A / o CURRENT LOCAL AGENCY FACILITY ISD N APPROVED BY NAME PHONE N WITH AREA CODE C72- 41 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Qy YES NO [] �S O / CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 'W/II FOR A(3-288) IJNI�'7.�'IAL}1�0 DATA PROCESSING COPY f>