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STATE OF CALIFORR WATER RESOURCES CONTROL BOARD A FORM IA,, UNDERGROUND STORAGE TANK PROGRAM SITE l FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION LPRMANENTLY CLOSED SITE F'a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) A (.G FACILITY/SITE NAME t 2 CARE OF ADDRESS INFORMATION A^ /l� �j G ADDRESS /7G V,01(L 19 NEAREST CROSS STREET ✓Bw to iMimle 0 PARTNERSHIP 0 STATE AGENCY ❑ CORPORATION Cl LOCAL AGENCY 0 FEDERAL AGENCY ❑ INDIVIDUALS 0 COUNTY AGENCY CIN NAME �N STATE ZIP COAEel SITE PHOWE IL WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax it INDIAN EPA ID N ❑ If of TANK's 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTESEMLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME F CARE OF ADDRESS INFORMATION �R as Z n/c MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP 0 STATE-AGENCY ''/ a ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY /� C/tv /' 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME . CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ./!�/d Q L ,/e 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY /7 L V /2,/L�j 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE vk WITH AREA CODE 9Zr� y /c IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. EV III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY 1 COUNTY# JURISDICTION# AGENCY# FACILITY ID% [ rtrtV#of( /T�ANKS at SITE 771 = d I CURRENT LOCAL AQFNCY FACILIT1'_pM� APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER `/j_(j-,�rJ•�� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED G Zai 2 YES NO ❑ 6 CHECK# PERMIT AMOUNT SURCHAROCAMOUNT FEE CODE RECEIPT# BY:ass 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. .` 1 FORM A(3-2-BB) • I `y\\V7 DATA PROCESSING COPY `)