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STATE OF CALIFORNIV WATER RESOURCES CONTR�BOARD 4 SE )M1f Y FORM `A': UNDERGROUND STORAGE TANK PROGRAM SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EOTCHANGE OF INFORMATION ❑ 7 PERM A LV CLOSED SITE ONE ITEM ❑ Z INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME _ I CARE OF ADDRESS INFORMATION s, Z Lt12� ADDRESS fi) pd NEAREST CROS STREET ✓60110Ye 11dealPARTNERSHIP ❑ STATE AGENCY a� t ❑ CORPORATION ❑ LOCAL AGENCY 11FEDER I-AGENCY t7+ � , '( ❑ INOMWAL ❑ COUNTYAGENCY CITY NAME ^ STATE ZIP CODE SITE PHONE#,WITH AREA CODE i v CA2413 TYPE OF BUSIN SS: p DISTRIBUTOR F—] 4 PROCE350R -/Box it INDIAN EPA ID N r RESERVATION orMol TANK'# - ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE �J u h /vV 010 5 �f! NIGHTS: NAME(LAST,REST) PHONE N WIT AREA CODE NIGHTS: NAME(LAST FIRST) PHONE N WITH AREA CODE 'C2-?711 II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST 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 STATE ZIPCODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME 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#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE AMISS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 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 M JURISDICTION M AGENCY M FACILITY ID M M of TANKS N SITE i = = ln !dO CURRENT LOCAL AGENCY FACILITY M M APPROVED BY NAME PHONE M WITH AREA CODE PERMIT N ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L ON C DE CENSUS TRAC SUPERVISOR-DI8TI11 ODE BUSINESS PLAN FILED DATE FI�De1O0�~11 DN YES NO :-1 C# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: o THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORE'+(3-2-f)e) � • 2 (71-0-`�(