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STATE OF CALIFORNIAO WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM S�T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' o COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 1pri CHANGE OF INFORMATION ❑ 7 FERMAN D SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) A FACIU /SITE NAME CARE OF ADDRESS INFORMATION ewevi ADDRESS < p� NEAREST CROSS STREET ✓8%kInhxxa Cl PARRIE&P ❑ STATE AGDO 5,5 S "U 11� 0 I�WAioN 0 AAGBO Cl FEDBVLAGRO CITY NAUEIIISTATCA ZIP ODE SITE PHONE K,WITH AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PNHSSDR ✓Box if INDIAN EPA ID p If of TANK's RESE ❑ 1 GAS STATION ❑ 3 FARM E�JOTHER TRUSTVATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE x 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 II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz t0 intlitate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY Cl 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 ✓Boz to Intlitele ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl 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: 1. ❑ if. 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 M JURISDICTION M AGENCY M FACILITY ID MS of TANKS at SITE = o - a[ , _7 101010101_ AGENCY FACILITY ID 4 APPROVED%%•"NAME PHONE a WITH AREA CODE CURRENT LO is 3 O PERMIT UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CO CENSUS TRA • SUPERVISOR-01 i ICT COD! BUSINESS PLAN FILED NG ❑ DATE FILED O CHECKa PERMIT AMOUNT SURCWUIGE AMOUNT FEE CODE RECEIPT By- 2 / THIS FORM MUST BE ACCOMPANIED BY AT LEAST V MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIO N ON I zRM A(3-2-88) DATA PROCESSING COPY 0