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STATE OF CALIFOR& WATER RESOURCES CONTROL BOARD S 1 f FORM A: UNDERGROUND STORAGE TANK PROGRAM = ' SITE /Y FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE w / 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INF RMATION I F`Q IT-'1 ADOR S NEARES CROSS STREET ✓ eta in�irale ❑ PARTNERSHIP ❑ STATE AGENCY C fAAPORATION ❑ LOCALAGENCI ❑ FEDERAL-AGENCY 31 J SUY\ W ❑ INDIVIDUAL Cl COUNTY AGENCY CITY NAME Q /\ STATCA ZIP \Sa SITE PHONE p.WITH AREA CODE I L TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR -,//Box if INDIAN EPA ID ft _ N of TANK's RESERVATION or El -,_� AT THIS S1TE D ❑ 1 GASSTATION ❑ 3 FARM E31- 01FHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS' NAME( ST,FIRST PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE l WITH A EW! NIGHTS. NAME(LAST,FIRST) PHONE p WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME v_v CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME �^^,, nn CARE OF ADDRESS INFORMATION VP MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE p,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) GATE LOCAL AGENCY USE ONLY COUNTY X rJURISD�TION# AGENCY N FACILITY ID% N of TANKS at SITE ® O l I (� I l, CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M'� SUPERVISOR-OIST�ICT CODE BUSINESS PLAN FILED DATE FILED OOl V lJ (! YES NO EDS- f\ 1I CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 0 BY: 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF LITE INFORMATION ONLY./^ iv�\`11 FORM A(3-2-BB) 0 DATA PROCESSING COPY .�