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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5E� rtiA FORM A. .. as UNDERGROUND STORAGE TANK PROGRAM = " bo Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT p 5 CHANGE OF INFORMATION ❑ 7 PERMAN NTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W 4 FACILITY/SITE NAME 11114 CARE OF ADDRESS INFORMATION -TtU7r-�2 R7ri /dark s ADDRESS _ NEAREST CROSS STREET ✓B"Irior le ❑ PARTNERSHIP ❑ STATE AGENCY �Q ..5 E CORPORATION Cl LEGAL AGENCY E FEDERAL AGENCY S U Cl INDIVIDUAL Cl COUNTY AGENCY CIN NAME STATE ZIP CODE ` SITEFPIH(41NE p. ITH AREA CODE Z l V _ qq6 q D TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID a ❑ 5OTHEA TTYo N Tof T NK's I GASSTATION 3FARM ❑ TRUST ❑ ATHIS 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 NIGHTS: NAME(IAST, ST) PH NE N WITH AREA CODE NIGHTS. NAME(IAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 6 s MAILING or STREET ADDRESS '^ -/Box to indicate E PARTNERSHIP ❑ STATEAGENCY Q F I ❑ CORPORATION Cl LOCALAGENCY ❑ FEDERAL AGENCY Cl INDIVIDUAL ❑ COUNTYAGENCY CITY NAME J� ` �n STATE ZIP CODE PHO Ep,WITH AREA CODE µ �G III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME _/� � " "" CARE OF ADDRESS INFORMATION (�ca�ilWl MAILING or STREET ADDRESS ✓Box to intlicate E PARTNERSHIP E STATEAGENCYdGkTar� C ❑ CORPORATION ❑ LOCAL AGENCY E FEDERAL AGENCY ( J E INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME l STATE 21P CODE_��0 / PHONE#;'WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS 9 LV 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 R JURISDICTION R AGENCY N FACILITY 10 N N of TANKS at SITE �9 = = 160 1 ] 2-1 101iv CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE I 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIFIAVAOM DATE f FRM CODE CENSUL SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F/ED I I YES ❑ NO ❑PERMIT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 8) DATA PROCESSING COPY l