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STATE OF CALIFORNIV WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) I"'' to FACILITY/SITE NAhjIETCCARE OF ADDRESS INFORMATION olhonea- ADDRESS NEAREST CROSS STREET ✓Bm to ilbifale PARTNERSHIP 0 STATE AGENCY L^ ,,=,0mATl0N Cl LOCAL AGENCY ❑ FEDERAL IIIA DNIDUAL ❑ COUNW AGENCY CITU NAME L_ O �'-1'_ STgTCA ZIP t SITE PHONE k,WITH ARE ODE TYPE OF BUSINESS. ❑ F—]2 DISTRIBUTOR 4 PROCESSOR I/Box if INDIAN EPA 10 N (1J /V\ If of TANK's E] I GAS STATION [:] 3 FARM �OTHER TRUSTRESEVLANDS ATION or ❑ AT THIS SITE 0 l EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST, IRST) PHONE k WITH AR A CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) j PHONE 9 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME Ott t CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME / _\ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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. � IL ❑ 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 If AGENCY# FACILITY ID# It of TANKS at SITE � [= = 10101Z12- lZ19-1b0 vl CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE If WITH AREA CODE L . I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAF CODE CENSUS TRACT#v SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED NO ❑ DgTE EILED� I 4 IL CHECK# PER IT AMOUNT SURCHARGE AMOUNT 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 ONLY FORMA(3-2-88) DATA PROCESSING COPY i