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STATE OF CALIFORNIA WATER RESOURCES CONTROL 'BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o SITE A- FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Ev, CHANGE OF INFORMATION ❑ 7_EEBMAKNTLY CLOSED SITE FJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 I. FACILITY(SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 00 W FACIUTY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS n NEAREST CROSS STREET ✓Malo iMicaw ❑ PARTNEIG1IP ❑ StATEAGFNLY /?,o O CgHPoAANt10N ❑ ryAGENp C] FEDB111l A6ENGY CITY NAME [' • STATE ZIP CODE SITE PHONE WITH AREA CODE plN CA yS Z O j� /J,e TYPE OF BUSINESS: DISTRIBUTOR F-1d PROCESSOR ✓Box if INDIAN EPA ID N ❑ ❑ RESERVATION or El of TANK'L 1 GAS6TATION 3 FARM 5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE /c 6//-1' /c < NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & DDRESS - (MUST BE COMPLETED) NAME F� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY p ❑ CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY �j F� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME // ,^, STATE ZI�OE�O / PHONE p,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME / n CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ 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: L ❑ If. 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# AGENCY# FACILITY ID J #of TANKS at SITE ao oat CURRENT LOCAL AOEN YFACILITY D N �T�� APPROVED SY NAME PHONE k WITH AREA CODE PERMIT NUMBER /PEERRMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONCODE CENSUS TRACTk SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE`FILED p Z 2 YES NO Elv—/3-0 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY:/- //Z� 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(3-2-511) DATA PROCESSING COPY