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STATE OF CALIFORNI91 WATER RESOURCES CONTRMOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT En 5 CHANGE OF INFORMATION ❑7 PERMANENTLY r'nSEO SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS —(MUST BE COMPLETED) FA�ILIIYrE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ambraw 0 PARINEfN11P ClSTATEdGEo 6 n w / ❑ ODWMTNN ❑ UXAAGENCY ❑ MEPkLAGD Y O� 6 ❑ INGmlwu ❑ c0LNlY4 B+Cr CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE �r� �o� CA Sy36 �- TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz N INDIAN EPA ID N F of TANK'N RESE ❑ 1 GAS STATION G21FAFM ❑ 5OTHER TR STYATION tANDS or ❑ FA/" ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE J, z09-73 - 17s) d UY� 2�9-931-i yS"l NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE It. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NA CARE OF ADDRESS INFORMATION as MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP - D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME�-" CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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: L ❑ if. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID It N of TANKS At SITE " = = = a6 0101ML CURRENT L CAL AGENCY FACILITY IDN APPROVED B NAME PHONE N WITH AREA CODE '� PERMITNUMBER PERMIT APPROVAL DATE PERMIT EKPIRATION DATE LOCATON CODE CENSUS TRACT P SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DATE FILED Q 3- 9_:3,2T__ YES NO ❑ "7117192 CNECKN PERMIT AMOUNT SURCHARGE OUNT FEE CODE RECEIPT BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION NLY. \ AFA(3-2-SB)