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m��.....r=.-.-.—�.-v....f.�.-..- ....r -mf.._+!xSii"TN'+.r..-..TTi'•.e. e.�.�... -. .�nn...Tvrnr. ♦ -moi.�,r�^rr�... STATE OF CALIFORNO WATER RESOURCES CONTRROARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o ii COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 195 CHANGE OF INFORMATION ❑ 7 PE ANENTL CL EO SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) O) O FACILITYIS��1ITTE�NAME CARE OF ADDRESS INFORMATION VC© e IsO 'cI _ �c`F�OTIc PeTN aNN� ✓J ADDRESS y� �/ '/y .�♦ p NEAREST C SS/STREET ✓Ba wrxiii ❑ PARTNERSHIP ❑ STATE AGENCY J SO SCC+I(j7`-7 LSI ` Ivya l,/ r ✓"'� ❑ NON OU LIQ ❑ fAUN1Y AGENC! ❑ EEDEML-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE ack-461i CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box i1 INDIAN EPA ID p RESERVATION or X of TANICX ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ ATTHIS 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) CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCALAGENCY ❑ FEDERALAGENCY ❑ 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 5 p MAILING or STREET ADDRESS ✓Box tocd,cate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ 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: I. IV II. ❑ 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 X JURISDICTION X AGENCY X TtCPP'FB-1 X of TANKS at SITE DTLOCAL � iC APPROVED BY NAME PHONE Al WITH AREA CODE UMBER ATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED .23 s 2_� •'3 5— YES [:] L NO 6 CHECKX PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At BY: G THIS FORM MUST BE ACCOMPANIED BY AT LEAST#MORE TANK PERMIT FORM 'B'APPLICATION(S), UIt THIS IS A CHANGE OF SITE INFORMATION ONLY FORMA(3-2-&&) DATA PROCESSING COPY