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S STATE OF CAL I FO R waTE yE�4:o. R RESOURCES CONTROL BOARD �URlx� F FORM 'A': <- UNDERGROUND STORAGE TANK PROGRAM Jill . SITE // ' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r � {(�f COMPLETE THIS FORM FOR EACH FACILITY/SITE gyros N. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7TLY LOSER SITE N ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE j� G G71 I. FACILITY/SITE INFORMATION &ADDRESS -- (MUST BE COMPLETED) N FAGiLITYlSITE NAME W CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BoxbIdENCY ElORA ule ❑ PARTNERSHIP ❑ STATE-AG 5 �Pa 6 +tel CORPTION ElLOCAL-AGENCY ❑ FEDERAL-AUNCY El IN mm 11COUNTY-AGENCYCITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CA CODE TYPE OF BUSINESS: ❑p DISTRIBUTOR ROCESSOR ✓Bax it INDIAN EPA ID N ❑ 1 GAS STATION ❑3 FARM 5 OTHER RESERVATION or ❑ #of TANK's �7 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 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS -- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl-CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY 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 ✓Box la indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE H,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: 1. ❑ it. ❑ III,❑ THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPI IGANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE C 'r / [�/Mv12j"L --- CURRENT LOCAL AGENCY FACILITY ID N �� APPROVED BY NAME PHONE N WI AREA CO PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ?i7j 2 YES NO CHECK N PERMIT AMOUNT SURCHARGE A OUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEj1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.. �N F� ��/ DATA PROCESSING COPY