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ori STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM E" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACN F CILITY/SITE MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑N AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION AI ADDRESS—(MUST BE COMPLETED) FACILITY/SITE NAME ^� CARE OF ADDRESS INFORMATION /V ADDRESS �'//�, NEAREST CROSS STREET ✓Babihn ❑ PWNMP ❑ STATE-AGDO ( 5 Ae�T�t�le O MWWOON 0 SCUM cl 0 PEBERN#GENCY CITY NAMEyv _—1— A STATE ZIP CODE SITE PHONE M,WITH AREA CODE� TYPE OF BUSINESS: ❑2 DSTRBUTOR ❑t PROCESSOR ✓Box R INDIAN EPA IDN 9 oj/LA ❑ I GAS STATION E]3 FARM ❑ 5 OTHER TRUSTTILANDS RESEATIONm ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: E(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE yN 2 � % Z NIGHTS NAME(LAST RST) 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 ✓Boa W indicate 0 PARTNERSHIP - 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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 ✓Boa loinoicele 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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. ❑ II. ❑ Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION B AGENCY N FACILITY IDN Nal TANKS Nt SITE = = � 0s 01 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE (� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �� _; �pJ �. , � �.. YES � NO ❑ 7-3� CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST 8E ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY': FORM A(3-2-68) • • -