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STATE OF CALIFORNR WATER RESOURCES CONTROL BOARD J� FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;l�° o COMPLETE THIS FORM FOR EACH ACILITY/SITE �'"F�^"" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2f 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED 2SITE ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) A FACT /SIT NAMEnn ,�HH 12 CARE OF ADDRESS INFORMATION W/L ADDRESS NEAREST CROSS STREET ✓Bw lDiNcile ❑ PARTNERSHIP ❑ STATE AGENCY ID 0 /� 0 C DW DU➢ON 0 LOCAL FIry AGE NCY ❑ FEDERAL AGENCY CITY A STATE ZIP ODE SITE PHONE ft,WITH AREA CODE q( C CA TYPE OF BUSINESS: ❑ 2 TRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'e / ❑ 1 6A$STATION 3 FARM 5 OTHER TRUSTVLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE IT WITH AREA CODE DAYS. NAME(LAST,FIRST( PHONE#WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE IT WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) ryA CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.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. ❑ it. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE 1751 1141 0= CURRENT LOC L,{.G�IICy7FACILI PERMIT NUMBER/"""J111/1y I # APPROVED BY NAME PHONE#WITH AREA CODE 1(L` PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC IO CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE RUSINESY PLANFILED NO ❑ DA F ED / [CCME�CK* `PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. / FORM A(3-2-88) DATA PROCESSING COPY 0 J