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STATE OF CALIFORNIP WATER RESOURCES CONTROrBOARD y FORM `A': UNDERGROUND STORAGE TANK PROGRAM = ' n SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION A 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EtTtANGE OF INFORMATION ❑ 7 PER TLY CLOSED SITE 1-a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Cn N FACILITY/SITE NAME f}M A CARE OF ADDRESS INFORMATION l"Rt>S i� ADDRESSNEAREST CROSS STREET Brix lcirerale D PARTNERSHIP D STATEAGENQ' �q p ❑ CORPORA71ON D LOCAL AGENCY D FEDERAL AGENCY �� ❑ INDIVIDUAL D COUNTY AGENCY CITY NAME 5 ATE l\ ZIP CODE Nil SITE PHONE p,WITH AREA CODE S //\ CA U/ TYPE OF BUSINESS'. EPA ID p 2 flIBUTOR 4 PROCESSOR ✓Bax if l DIAN O RESERVATI / X of TANK's ❑ I GAS STATION 3 FARM QjHFP -- TRUE` DS ❑ AT THIS SITE 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 NIGHTS: NAME(LAST FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATEAGENCY Cl CORPORATION D LOCALAGENCYD FEDERALAGENCY D INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE if,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION C1�e C1 MAILING or STREET ADDRESS ✓Box to Indicate D PARTNERSHIP D STATE AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL AGENCY D INDIVIDUAL D COUNTYAGENCY CITY NAME STgTE 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: I. IV it. ❑ Ill. ❑ 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 X JURISDICTION X AGENCY11, FACILITY ID X X of TANKS at SITE M101 o 141 Gov 1 e4 CURRENT LOCAL AGENCY FACILITY IDX APPROVED BY NAME PHONE X WITH AREA CODE I'W PERMIT NUMB R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TR''A//C�T1M SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED p 27 /r YES ❑ NO ❑ 6 CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X BYe J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FORMA(3-2-86) • DATA PROCESSING COPY • '�.�/