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STATE' OF CALIFORNIA* WATER RESOURCES CONTROL BOARD r "' FORM A: UNDERGROUND STORAGE TANK PROGRAM = " A,o Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; a COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7-FZBUANJNTLY CLOSED SITE F"a ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C3 —4 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N FACILITY/SITE NAME Z.GARE OF ADDRESS INFORMATION ADDRESS / W NEAREST CROSS STREET to inbI C PARTNERSHIP 0 STATE AGENCY CORPORATION C LOCAL AGENCY Cl FEDERAL AGENCY ❑ INDIVIOUAL 0 COUNTYAGENCY CITY NAME Y STATE ZIP CODE SITE PHONE 4,WITH AREA CODE CA 9 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I/Box if INDIAN EPA ID # If of TANK'S ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSESET LAN S ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE C/16 G4-1 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS�-, I(MUST BE COMPLETED) NAME nn /� -TAIL CARE OF ADDRESS INFORMATION /c� - MAILING or STREET ADDRES ✓Box to,ndicate 0 PARTNERSHIP 0 STATE-AGENCY 1 Y3 CORPORATION C LOCALAGENCYC FEDERAL-AGENCY n j ()e V121ef ❑ INDIVIDUAL C COUNTY-AGENCY CITY NAME STA T^^E nn ZIP CODE PHONE IF WITH AREA CODE it i.� III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME ^ \ �1/� �� IA�/�f•. CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ,w I S ✓Bax to mdIcate 0 PARTNERSHIP Cl STATE-AGENCY v�r `\ I ❑ CORPORATION ❑ LOCAL-AGENCY C FEDERALAGENCY 'V C INDIVIDUAL C COUNTY-AGENCY CITY NAME /, STATE ZIP CODE PHONE#.WITH AREA CODE (��' S IV. LEGAL NOTIFICATION AND BILLING ADDRESS CNECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. LIZ 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# AGENTCY# FACILITY ID# IF of TANKS at 7SITE IBJ V CURRENT LOCAL AOLAMENT ^ APPROVED BY NAME PHONE#WITN AREA CODE PERMIT NUMBERMMIT'•APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CO E SUPERVISOR-DISTRICT CODE BUSINESS PSN FILED NO DATE FILED1 6CHECK# SURCHARGE AMOUNT FEE CODE RECEIPT# BY / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESSTHIS IS A CHANGE OF SITE INFORMATION ON FORMA(3-2-88) ✓`l DATA PROCESSING COPY