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�1�-- STATE OF CALIFORA WATER RESOURCES CONTRIP BOARD a FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o C COMPLETE THIS FORM FOR EACH FACILITY/SITE °'4roxe`r MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED BITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O N Ito I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION R ADDRESS NEAREST CROSS STREET ✓Barb idinN ❑ PAATNERNIN ❑ STATFAGSNCY ❑ COWBIANON B'CG^,A-AGENC/ ❑ FEDERALAGENCY ❑ INDMIXAL ❑ COUNTY-AGENCY CITY NAME ��, STATE ZIP CODESITE PHONE k,WITH AREA 1, (tI�C CA fJ ftu TYPE OF BUSINESS: ❑ 201SMIGUTOR ❑ 4>CESSORINDIAN EPA ID# ❑ 1 GAS STATION ❑3FARM OflETHER 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#WITH AREA CODE �/H1h 38 NIGHTS: N E(LAST. RST) ONE#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 4L /lZE S MAILINGdr STREE/TA`DDRE_S �^ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 13 T `-'A• / ❑ NDRVIOUALION ,ry AGE CY ENCY ❑ FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE S30 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMEi- CARE OF ADDRESS INFORMATION mo / s�rr MAILING or STREET ADDRESS Box to indicate Cl TNERSHT ❑ STATE-AGENCY ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY / ❑ INDIVIDUAL ❑ COUNT'-AGENCY CITY NAME ^ Lr//" STATE ZIP CODE PHONE#,WITH AREA CODE i/! IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. ❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# If of TANKS at SITE II d c�I / I v I / 01010 171 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [CHECi OCATION CODE CENS�U'TS TRA��CTM) SUPERVISO -DISTRICT CODE BUSINESS PLAN FILED DATE Fl D 7 0 � �/ VES NO ❑ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY' 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 0 Y. FORMA(3-2-88) DATA PROCESSING COPY